Register for Online Services

To register for our online services you will need to complete this form. We will then contact you and let you know how to provide your two forms of identification. Please do not attend the surgery.

Once you are registered, we will issue you with a username and password, and you will be able to use the service to:

• Order your repeat prescriptions
• Cancel an appointment
• Change your contact details

Register for Online Services

Register for Online Services

If you are human, leave this field blank.

Full Name: *

Date of Birth: *

Please use this date format: DD/MM/YYYY.

Phone Number:

Email Address: *

Any responses we send will go to this email address.

Address, including postcode:

Terms and Conditions

I understand that it is my responsibility to keep my account secure by keeping my details confidential I understand that I can terminate my account at any time by contacting the surgery, or change my log in details by re-registering and that this form will be kept on my electronic records I understand that my registration will be revoked if I constantly miss or cancel appointments.

*

I accept the terms and conditions stated above