Patient Registration Form For Online Services

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Patient Registration Form for Online Services
Appointment booking and cancellation
Have the flexibility to book, check and cancel your appointments from home, at work or any location
with internet access. You don’t need to queue at the practice or wait on the telephone and you can
manage your appointments outside practice opening hours. Patients can book GP appointments up to
2 weeks in advance and nurse appointments up to 6 weeks in advance. A maximum of 3 booked
appointments can be made per patient. Please remember to cancel any unwanted appointments as
soon as possible.
Request your repeat prescriptions online
Request your repeat prescriptions quickly online by logging into your account and simply ticking the
appropriate boxes. You can review the progress of your repeat prescriptions and read any messages
that the practice may have sent back to you. You should allow 48 hours from submitting a request
before collecting your prescription.
Access your medical record online
Currently you may view only allergies and all past and present medications. In the future this will
expand to include test results, immunisations, details of consultations and your medical history.
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
(Photo identification required)
Patient details
Please complete in BLOCK CAPITALS
Patient forename
Patient surname
Date of birth
D D / M M / Y Y Y Y
Email address
(to send you reminders
and notifications)
Mobile number
Please sign and date
Print forename
Print surname
Relationship to
Delete as appropriate
patient
(if completing the
Parent
form for someone else)
Carer
Signature
D D / M M / Y Y
Date
Please read overleaf
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Rainhill Village Surgery

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