Patient Registration Form For Online Services (Page 2 of 2) in pdf

Patient Registration Form For Online Services Page 2

Patient Registration Form

Who can apply?

Patients must be aged 12 years or older to register for an online account. Parents (or those with

parental responsibility) may apply for an account on behalf of their children where both parent and

child are registered at the Practice, and the child is under 12.

Carers may apply on behalf of patients they care for if the carer has legal power of attorney or has been

given explicit written patient consent.

By signing overleaf I confirm that:

I have read and understood the information provided to me by the practice

I will be responsible for the security of my username and passwords and the information that I

see or download

If I choose to share my information with anyone else this is at my own risk

I will contact the practice as soon as possible if I suspect that my account has been accessed by

someone without my agreement

If I see information in my record that is not about me, or is inaccurate I will log out immediately

and contact the practice as soon as possible

I agree to use the system in a responsible manner in accordance with all instructions given to

me by the Practice. If not, access may be withdrawn.

I agree that my details may be used to contact me with information about my online account

and the online services I use. I agree that I may also be contacted by text message or email

about how useful I find the services, whether they could be improved and also to send updates

and reminders relevant to my care.

I agree that I cannot use this service as a means of communication with the surgery for other

purposes and will not use it for urgent matters.

Practice use only:

Identity verified

Name of verifier:

Date:

Passport (_________)

through (record

last 3 digits of

Driving License (_________)

number)

Date account

created

Date passphrase

sent

If you are interested in finding out more about the Vision clinical system we use at our GP practice

please visit

Patient Registration Form For Online Services Page 2