Online Patient Access request form

Use this form to request only access to your medical records or to manage your repeat prescriptions. We will get back in touch with you to verify your identity and then send you a key to get access.

Last Updated: 12/03/2021

Your details

First Name *

Surname *

Date of Birth *

Your contact details

Please make sure you fill in at least one

e-mail address

Telephone number

Mobile number

Which services do you want access to online

Please tick those that apply

Services required

Requesting repeat prescriptions

Accessing medical records

Are you requesting access for yourself, or someone else? *

I'd like access to my own records

I'm requesting access to my child's records

I'm requesting access to the records of someone I care for.

Consent

It's important that your information is kept private and secure

I understand and agree with each statement (please tick)

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

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

If I think that I may come under pressure to give access to someone else unwillingly I will contact the practice as soon as possible.

Setting up a video call so we can verify your identity

So that we can check that it is really you who wants access to your records, we may ask to set up a 5 minute video call and ask to see some photo id. We do this by sending you a link to click on to join the call

Do you have the following (please tick those that apply):

A tablet, smart phone or PC with camera and microphone that you can use for the video call

Official photo id such as a passport or driving license that you can hold up to the camera

How would you like us to send you the link to start the call

To my mobile phone number as a text message

To my e-mail address

Any other comments?

Online Patient Access request form

Further Information