Online Access 16+ – Farnham Park Health Group

To view your allergies and immunisations, order repeat prescriptions please complete the form below. You may be be required to present a form of ID in order to assist us with verifying your identity. You will be issued with your personal online access details enabling you to register for patient access using the NHS App or other providers.

Complete and submit the appropriate form alternatively contact the IT Support Team. [email protected]

This form is to be completed by patients aged 16 and over for online access.

Online Access

We are asking all new patients who register with us to download the NHS App to enable you to: Renew repeat prescriptions Securely access your medical records Check your symptoms, get instant advice, and more Please note – The medical records will be from the date of registration

Name(Required)

Prefix First Last

Date of Birth(Required)

Email(Required)

Online Access(Required)

Pin Details to be sent via email

Pin Details to be sent by Post

I would like to collect my PIN details from reception

Online Declaration

If you are happy with the information provided for online access to your medical records please tick the boxes below and sign and date your acceptance for online access.

I will be responsible for the security of 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 contact the practice as soon as possible

Identification

Max. file size: 10 MB.

Please upload a form of identification suitable for us to verify for approval of online access. Photo Identification Driving Licence Passport Student Card

Patient Signature

Date

Online Access

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