Do not turn up at your Practice without an appointment.

Do not turn up at your practice without an appointment. Phone first or follow the advice on our website.

The Orchard Medical Practice > Your Record > Keep us up to Date > Register for Online Services Form

Register for Online Services Form

Please note, if you wish to register for online services, please complete this form. Once your application has been received we will issue you with the necessary documentation so you can then register for online services. If you have any further questions please contact the Practice.

First Name *

Last Name *

Email *

Enter Email

Date of birth *

Please use format day/month/year e.g. 12/05/1979

Phone Number *

Address *

I wish to have access to the following online services *

Booking appointments

Requesting repeat prescriptions

Accessing my medical record (when available)

Please tick all that apply

I wish to access my medical record online and understand and agree with each statement below:

I will be responsible for the security of the information that I see or download *

I agree

If I choose to share my information with anyone else, that is at my own risk *

I agree

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

I agree

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

I agree

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 *

I agree

Please list your current repeat medications below

Current Medications

Privacy Policy

This form collects your name, date of birth, email, other personal information and medical details. This is to confirm you are registered with the practice, to allow the practice team to contact you and also to update your medical records held by the practice and our partners in the NHS. Please read our Privacy Policy to discover how we protect and manage your submitted data.

I consent to the practice collecting and storing my data from this form.

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Do not turn up at your Practice without an appointment.

Register for Online Services Form

I wish to access my medical record online and understand and agree with each statement below:

Please list your current repeat medications below

Privacy Policy

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