Access to Core Online Services (appointments & repeat prescriptions)

This will give you basic online access via our Patient Access portal and will enable you to book/cancel appointments, request your repeat medications and send messages to the practice team.

Last Updated: 11/11/2020

Patient Details

Surname *

First Name/s *

Date of Birth *

Full Address including Post Code *

Contact number *

email address *

** IMPORTANT INFORMATION **

Please note: to enable us to process this request, your contact number and email address MUST match the ones we hold on your medical record. If this is not the case, we will require PROOF OF PHOTO ID before access is granted. We will advise you by email if we require this.

SIGNATURE **

** By typing the name in the signature box you are entering into a legal contract and confirming that you are the person named in this application

I confirm that I am the person named above and would like to request access to my CORE online record summary via Patient Access *

Yes No

Signature *

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Access to Core Online Services (appointments & repeat prescriptions)

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