Online Access Registration Form - Nettleham Medical Practice

You can set up an online account to request prescriptions and view your medical record by showing some identification to our reception team. You will be able to view information that was recorded on or after the date that your account was set up.

If you have set up an account and would like to view information recorded from the date that you registered with the practice (if you were registered with us before setting up your account) you can request this by completing this form.

Your request will be verified by a GP and can take up to 28 days. Please note that any access you already have will be switched off whilst your request is processed.

Online Access Registration Form

Name

First

Last

Date of birth

Address

City

State/Province

Zip/Postal

Email address

Telephone number

Tick to agreement with the following statements:

1. I already have an online account username and password

2. I have read and understood the information leaflet provided by the practice

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

4. If I choose to share my information with anyone else, this is at my own risk

5. I will contact the practice as soon as possible if I suspect that my account has been accessed by someone without my agreement

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

Consent

I wish to have access to my full medical record from the date I registered with the practice.

If you are human, leave this field blank.