First name Last name
Date of birth SexMaleFemaleOther
Postcode Phone
Email Address, including postcode
Booking AppointmentsRequesting Repeat MedicationsAccessing My Medical Record
I have read and understood the NHS approved information leaflet 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.
If I suspect unauthorised access, I will contact the practice as soon as possible.
If I see information that is not about me or is inaccurate/upsetting, I will contact the practice as soon as possible.
If I think I may come under pressure to give access to someone else unwillingly, I will contact the practice as soon as possible.
I accept the terms and conditions stated above.
Signature (type full name) Date
