Online Report Access Application Form

If you would like to request online access to your records please use this form.

Once your request has been processed, please visit the surgery with your forms of ID to collect your log in details.

Online Records Access Application Form
Title: *
Please use format DD/MM/YYYY
All responses will go to this email.

General Questionnaire

Please answer the following questions when considering if you would like online access to your medical records
I am doing this questionnaire for myself *
Can you read and understand English? *
Have you registered for ordering repeat prescriptions and booking appointments online? *
Are you happy to use passwords to access your record? *
Would you like to feedback what you think of the records access system? *
There may be an instance when accessing your medical records online, you may read some information that could be shocking or upsetting. What do you do if this happens and you cannot speak to your doctor/nurse immediately?
Would it upset yo if you read something somebody else has said about you with regards to your health?
Do you feel you understand what Online Records Access means? *

Online Access

I wish to have access to the following online services (please tick all that apply)
I wish to access the information I have specified above online and understand and agree with each statement below (tick) *

Please note if you do not agree to all the above points your application will be declined.

For office use only