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Online Access application form




The following Terms and Conditions are for patients to sign before being allowed to access clinical system direct online facilities, such as prescription ordering, appointment booking, or personal profile updates.


One of the following checks should be carried out to ascertain the patient’s identity:


    • Checking photo ID and proof of address, for example, a passport or driving licence and a bank statement or council tax statement
    • If the patient has no ID but is well known to the surgery, a member of staff may be able to confirm their identity.
    • If the patient has no ID and is not well known to the surgery, the ability to answer questions about the information in their GP record may confirm that the record is theirs.

Terms and Conditions

    • To apply for online access to the Practice’s clinical system, patients must complete the declaration below and return this form to Reception.
    • Applications are “one per patient”. Acceptance of one member of a family does not imply acceptance of other / further family members.
    • Applications for online access will not be considered for patients who are under the age of 16.
    • You can choose to let another person see your medical records, for example members of your family or a carer. To do this safely, contact the practice manager at the surgery.
    • Where access is refused this will be in writing, a reason will only be given at the discretion of the Partners.
    • Patients with a history of non-attendance at pre-booked appointments (without cancelling) will not normally be granted access to on-line appointment booking, however the remainder of the facilities will be considered.
    • Appointments booked online are to be cancelled by the patient as soon as it is determined that it is no longer required.  
    • The Practice will not allow misuse of the online system and will monitor usage by individual patients. Where it is considered that a patient is misusing the system or is acting in a way detrimental to the availability of the appointment system, or other facilities, a warning letter will be issued. Where the situation does not improve, or recurs, access will be removed permanently and without further notice, at the discretion of the Partners.
    • Repeat prescriptions may only be ordered where these appear on the repeat list, which is provided to patients on the tear-off portion of the last prescription issued. The request must match the repeat list exactly and must be due. Other items ordered or requested using this facility will not be actioned, and no contact will be made with the patient. Prescriptions ordered outside this guideline must be via reception staff. We still require 2 working days notice to process prescription requests.
    • Personal Information updating is subject to validation after submission.
    • Approved access requests will be notified along with access instructions and a copy of these Terms and Conditions.
    • Requests for reissuing of access log-in details will be responded to via reception
    • If you change surgeries, you will need to register again for online services at your new surgery.
    • You can choose to stop using online services at any time by informing reception


I agree to the above Terms and Conditions, and others which may be reasonably imposed from time to time at the discretion of the Partners.


Name: ……………………………………………………………….. Signature……………………………………………….. Date………………


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