The Misbourne Practice

Patient Access application form (for online access to GP services)
Name		
Date of birth		
Address

	
Postcode		
Email address		Usual GP		
Telephone number		Mobile number		

I wish to have access to the following online services (tick all that apply):
1.	Booking appointments		
2.	Requesting repeat prescriptions		
3.	Accessing my medical record  - Medication and Allergies		
4.	Accessing my medical record – Test results and immunisations		
5.	Accessing my medical record – Problems, Consultations (coded data only)*		
6.	Accessing my medical record – Documents**		
*Please allow 2 weeks for this to section to be processed
**Not yet available
Application for online access to my medical record
I wish to access my medical record online and understand and agree with each statement (please tick)
A.	I have read and understood the information leaflet  provided by the practice		
B.	I will be responsible for the security of the information that I see or download		
C.	If I choose to share my information with anyone else, this is at my own risk		
D.	I will contact the practice as soon as possible if I suspect that my account has been accessed by someone without my agreement		
E.	If I see information in my record that it not about me, or is inaccurate I will log out immediately and contact the practice after 2pm		

Signature		Date	
	
Please return to Reception – NB ID will be required
For practice use only
Identity verified through
(tick all that apply)	Vouching 
Vouching with information in record    
Photo ID 
Proof of residence 	Name of verifier	Date	
Name of GP who authorised section 5
(if applicable)		Date