GP Online Services Access Request Form

If you wish to, you can now use the internet to book appointments with a GP, request repeat prescriptions for any medications you take regularly and look at your medical record online. You can also still use the telephone or call in to the surgery for any of these services as well.

Being able to see your record online might help you to manage your medical conditions. It also means that you can even access it from anywhere in the world should you require medical treatment on holiday. If you decide not to join or wish to withdraw, this is your choice and practice staff will continue to treat you in the same way as before. In general this decision will not affect the quality of your care.

You will be given login details, so you will need to think of a password which is unique to you. This will ensure that only you are able to access your record – unless you choose to share your details with a family member or carer.

The practice has the right to remove online access to services for anyone that doesn’t use them responsibly.

It will be your responsibility to keep your login details and password safe and secure. If you know or suspect that your record has been accessed by someone that you have not agreed should see it, then you should change your password immediately.

If you can’t do this for some reason, we recommend that you contact the practice so that they can remove online access until you are able to reset your password.

If you print out any information from your record, it is also your responsibility to keep this secure. If you are at all worried about keeping printed copies safe, we recommend that you do not make copies at all.

First name(Required)

Surname(Required)

Address(Required)

Street Address City Postcode

Date of birth(Required)

Email address(Required)

Telephone number(Required)

I wish to have access to the following online services (tick all that apply):(Required)

Booking appointments

Requesting repeat prescriptions

Accessing my medical record (Immunisations/Allergies/Adverse reactions)

Application for online access

I wish to access my medical record online and understand and agree with each statement (please tick)(Required)

I have read and understood the information provided by the practice

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

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

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

If I see information in my record that it not about me, or is inaccurate I will log out immediately and contact the practice as soon as possible

Disclaimer

The information you provide in this form will be processed by Cedar Practice. The information will be treated as confidential and stored in a secure data centre located in the UK. The information will be uploaded to your record in the practice’s clinical system as soon as possible after submission, after which the copy of your information in the data centre will be securely destroyed.

Please note that by using this form you will be sending information about yourself across the Internet. Whilst every effort is made to keep this information secure, you should be aware that we cannot offer any guarantees of absolute privacy. If this matter concerns you then you should use another method of providing this information.

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