Online Services Application Form

Online services Application Form
(If applicable)
(If applicable)

I wish to access online services and understand and agree with each of the following statements
(Please tick)

I wish to have access to the following online services
(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: