Stokenchurch Medical Centre, Oxford Road, Stokenchurch, Buckinghamshire, HP14 3XS	
Patient Online: registration form Access to GP online services
Name		
Date of birth		
Address

Postcode		
Email address		Usual GP		
Telephone number		Mobile number		

I wish to have access to the following online services (tick all that apply):
1.	Booking appointments		
2.	Requesting repeat prescriptions		
3.	Accessing my medical record  - Medication and Allergies* 		
4.	Accessing my medical record – Test results and immunisations*		
5.	Accessing my medical record – Problems, Consultations *		
6.	Accessing my medical record -  Documents & letters**		
*When made available at this GP Practice (March 2015 – March 2016) **When made available at this GP Practice
Application for online access to my medical record
I wish to access my medical record online and understand and agree with each statement (please tick)
1.	I have read and understood the information leaflet  provided by the practice		
2.	I will be responsible for the security of the information that I see or download		
3.	If I choose to share my information with anyone else, this is at my own risk		
4.	I will contact the practice as soon as possible if I suspect that my account has been accessed by someone without my agreement		
5.	If I see information in my record that it not about me, or is inaccurate I will log out immediately and contact the practice  immediately via ‘Secure Messaging’ within my Patient Access (if available) account or I will contact the practice by telephone after 2pm		
6.	If I have access to my childs record I understand that this will be switched off on the childs 11th birthday		

Signature		Date		
For practice use only
Identity verified through
(tick all that apply)	Vouching 
Vouching with information in record    
Photo ID 
Proof of residence 	Name of verifier	Date	
Name of person who authorised 
(if applicable)		Date	
Date account created 		
Date passphrase sent