Patient Access Form

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Patient's Details

Information we need to register you for Patient Access
Please note all fields marked with a * are mandatory for your registration

Type of Access required

I wish to have access to the following online services, please tick all that apply:


Note: If selecting this option, please allow up to 30 days for access or over 90 days if you are a new patient.

Understand and agree
Identification Upload

Patient Identification

To fully register you with Patient Access, we need two forms of ID (one photo ID and one proof of residence).

We will not store these documents and we will securely delete / destroy them after our initial verification.

Acceptable Photo ID: Photo Driving Licence or Passport

Acceptable Proof of Residence: Utility bill or Bank statement (date within the past 3 months), Tenancy agreement, Mortgage statement, Home/Car Insurance, Mobile phone contract etc.


What happens to my information?

Personal and medical information about patients registered at this practice are primarily kept electronically, although some is kept in paper form. Some information will be sent to hospital consultants and other health professionals to whom you are referred by your GP in order to provide continued healthcare and obtain treatment for you.

We sometimes use accredited suppliers for our communication with you, for example when we send recall letters for review clinics or medication reviews. All suppliers we use are checked carefully to ensure they comply with strict confidentiality protocols.

To ensure the security of all patient information, all staff that has access to your records is covered by confidentiality clauses in their contracts and the Data Protection Act and the Freedom of Information Act. Our guiding principle is that we hold your records in strict confidence.

I certify that the information I have provided is correct and consent to my personal and medical information being used as stated above.

Privacy Consent

This form collects personal and medical information about you. We use this information to allow the practice team to contact you. Please read our Privacy Policy to discover how we protect and manage your submitted data.


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