Register for NHS App Online Services

To register for the NHS App online services, you will need to complete this form.

We will then issue you with a linkage key, ODS code and account number.

Once you are registered you will be able to use the service to:

• Order your repeat prescriptions
• Make an appointment
• Cancel an appointment
• Change your contact details
• Review your medications and known allergies
• View your Health Records

Register for NHS App Online Services

Register for NHS App Online Services

If you are human, leave this field blank.

Are you registering for proxy access for another person? *

Yes

No

Patient Details

Full Name: *

Date of Birth: *

Please use this date format: DD/MM/YYYY.

Phone Number:

Email Address: *

Any responses we send will go to this email address.

Address, including postcode:

Proxy Details

Full Name: *

Date of Birth: *

Please use this date format: DD/MM/YYYY.

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

Terms and Conditions

• 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

Signature:

Date: