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Dedridge Medical Group > Your Record > Keep us up to Date > Register for Online Services Form

Register for Online Services Form

If you wish to register for online services, please complete this form. Once this has been verified, we will issue you with the necessary documentation so you can then register for online services. If you have any further questions please contact the Practice.

Note: Currently prescriptions ordering is the only available on line service. However if you would like to use an on line appointments system should this later be available or to access your record, again, should this become available you can still tick the boxes below.

First Name *

Last Name *

Email *

Enter Email

Confirm Email *

Confirm Email

Date of birth *

Please use format day/month/year e.g. 12/05/1979

Phone Number *

Address *

I wish to have access to the following online services *

*Booking / cancelling / viewing appointments

Requesting repeat prescriptions

*Accessing my Online Summary (Medications & Allergies) (#93440)

Please tick all that apply – *Booking appointments and online summary currently unavailable.

I wish to use Online Services. Please read each statement carefully and tick before signing.

1: I have understood the information provided by the practice *

I agree

2: If I choose to share my information with anyone else, that is at my own risk *

I agree

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

I agree

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

I agree

5: If I see information in my record that is not about me or is inaccurate, I will contact the practice as soon as possible *

I agree

Privacy Policy

This form collects your name, date of birth, email, other personal information and medical details. This is to confirm you are registered with the practice, to allow the practice team to contact you and also to update your medical records held by the practice and our partners in the NHS. Please read our Privacy Policy to discover how we protect and manage your submitted data.

I consent to the practice collecting and storing my data from this form.

I understand and agree with all the above statements:

Signature

Clear

Type your name to sign

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Public Holidays & Practice Closures

Register for Online Services Form

I wish to use Online Services. Please read each statement carefully and tick before signing.

Privacy Policy

I understand and agree with all the above statements:

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