Register for for NHS app online services

Are you registering for proxy access for another person? *

Yes

No

Full Name: *

Phone Number:

Address, including postcode:

Full Name: *

Relationship to patient: *

I wish to have access to the following online services:

Book and cancel appointments

Requesting repeat prescriptions

Change personal details

Access to summary care records (medication record, adverse reactions/allergies etc.)

Tick all that apply

I understand that it is my responsibility to keep my account secure by keeping my details confidential
I understand that I can terminate my account at any time by contacting the surgery, or change my log in details by re-registering and that this form will be kept on my electronic records

*

I accept the terms and conditions stated above

Signature:

Date:

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