New Road Surgery - Register for online services

To register for our online services you will need to complete this form and then visit the practice, bringing with you two forms of identification. One of these items should include your photograph.

We will then issue you a username and password.

Once you are registered you will be able to use the service to:
- Order your repeat prescriptions
- Make an appointment
- Cancel an appointment
- Change your contact details
- Review your medications and known allergies
Name*

First NameLast Name
Date of birth*

DayMonthYear
Date
Email*
example@example.com
Tel:
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Terms and Conditions

I understand that it is my responsibility to keep my account secure by keeping my details confidential I understand that I can terminate my account at any time by contacting the surgery, or change my log in details by re-registering and that this form will be kept on my electronic records I understand that my registration will be revoked if I constantly miss or cancel appointments.
I accept the terms and conditions stated above
Should be Empty: