Online Access Application Form – Gas House Lane Surgery

All patients wishing to use online services must complete this application form in full. Once this form is completed you will be given access to: Appointment booking, Medication requests, Test results, Detailed coded record access, Full clinical record access (from the date of registration with the surgery)

Complete the form below to have access to your online medical records

Full Name(Required)

Date of Birth(Required)

Home Address(Required)

Mobile Number(Required)

Email Address(Required)

Online Access - Practice Guidelines

All patients wishing to register for online access must read and agree to the following guidelines and sign to accept these terms. *Only patients who are over the age of 16 are able to register for this service *The practice will only accept applications from individual patients (example: wife cannot request online facilities on behalf of her husband etc.) *All patients will be expected to provide photographic ID as part of the registration process *This service, patient passwords and access rights must be treated with strict confidentiality. *Abuse of the system will result in patient access rights being revoked.

Please tick the box below to agree to the practice guidelines(Required)

I have read and understand the practice guidelines

Once this form is completed, you will recieve a text from the surgery. Please reply to this using the link with a photograph of your photo ID so we can complete this registeration