Application for online access to my medical record
Barton Hills Medical Group
Surname
*
First name
*
Date of birth
*
/
Month
/
Day
Year
Address
*
Street Address
Street Address Line 2
City
County
Post Code
Telephone number
Mobile Number
I wish to have access to the following online services (please tick all that apply):
Booking Appointments
Requesting repeat prescriptions
Accessing my medical record
I wish to access my medical record online and understand and agree with each statement (tick):
*
I have read and understood the information leaflet provided by the practice
I will be responsible for the security of information that I see or download
If I choose to share my information with anyone else, this is at my own risk
If I suspect that my account has been accessed by someone without my agreement, I will contact the practice as soon as possible
If I see information in my record that is not about me or is inaccurate, I will contact the practice as soon as possible
If I think that I may come under pressure to give access to someone else unwillingly I will contact the practice as soon as possible
Signature
Date
/
Month
/
Day
Year
Date
Submit
Should be Empty: