Online Services Application Form

Full Name *

Date of Birth *

Address

City

County

Postcode

Contact Number *

Home Phone

(If applicable)

Work Phone

(If applicable)

Email Address *

I wish to access online services and understand and agree with each of the following statements

1. I will be responsible for the security of the information that I see or download

2. If I choose to share my information with anyone else, this is at my own risk

3. I will contact the practice as soon as possible if I suspect that my account has been access by someone without my agreement

4. If I see information in my record that is not about me, or is inaccurate, I will log out immediately via “secure messaging” within my Patient Access account and I will contact the practice by telephone

5. If I have access to my child’s record I understand that this will be switched off on the child’s 12th birthday

(Please tick)

I wish to have access to the following online services

Booking routine GP appointments and cancelling appointments

Requesting repeat prescriptions

(Tick all that apply)

Additional services will be available upon request via your online account once your account has been activated

Accessing Summary Care Record: Medication and allergies
Accessing Summary Care Record: Additional information
Accessing detailed Medical Record from 1st April 2017

I have read and agreed the Patient Access to On-line Services terms and conditions document (available at reception and online on the Porch surgery website).
I accept that if I request access to the additional services this may take up to 2 weeks as all applications require GP review of medical records and approval.

For Housebound Patients Only

I would like to nominate a friend/relative/carer to collect my account details on my behalf.
I understand the person collecting my details will have access to my confidential account information and I take full responsibility for any misuse of my account or breaches of confidentially that may occur as a result.
The Surgery will contact the housebound patient to confirm the request prior to granting on-line access.

The full name of person I nominate to collect my account details on my behalf is:

Nominated Person