Patient Registration Form For Online Services (Page 2 of 2) in pdf

Patient Registration Form For Online Services Page 2

I would like to register to use the practice’s online services:

□ Online booking of appointments / cancelling

□ Online ordering of repeat prescriptions

I agree to use the system in a responsible manner in accordance with all

YES / NO

instructions given to me by the practice. If not access may be withdrawn.

I agree that it is my responsibility to keep secure the username and passwords I

YES / NO

will be given. If I think these have been shared inappropriately I will reset them

using the instructions supplied.

I agree that my details below may be used to contact me about useful I find the

YES / NO

service and whether it could be improved.

I agree that online services are provided at the discretion of the practice, and may

YES / NO

be withdrawn by the practice at any time.

PLEASE BRING SOME FORM OF PHOTO ID TO RECEPTION AND ASK TO

Patient details

Surname

First Name

Date of Birth

Address

Post Code

Telephone Number

Mobile Number

To be signed at Reception by patient: …………………………………………………

Print Name: ……………………………………………….

Date: ……………………………………………….

Page 2 of 2

Patient Registration Form For Online Services Page 2