New Online Registration Form

John Hampden Surgery

97 High Street, Prestwood, HP16 9EU

johnhampdensurgery@nhs.net

www.johnhampdensurgery.co.uk

Tel: 01494 890900

PLEASE COMPLETE THE BELOW APPLICATION, PRINT AND RETURN TO THE PRACTICE WITH PHOTO IDENTIFICATION. IF YOU DO NOT HAVE PHOTO ID WE MAY BE ABLE TO VERIFY YOU FROM INFORMATION CONTAINED IN YOUR MEDICAL RECORD.

Full Name*

First NameLast Name

Address*

Street Address

Street Address Line 2

Town / CityCounty

Post Code

Phone Number*

Area CodePhone Number / Mobile

E-mail

example@example.com

Registration History*

I wish to have access to the following online service within the NHS App.

Booking appointmentsRequesting repeat prescriptionsAccessing my medical record INCLUDES Documents / Letters Test Results Coded data, including Problems, Consultation entries and Immunisations

Please Specify*

IMPORTANT INFORMATION

Existing Patients

If you are an EXISTING patient and this is the first time you are requesting access to online services the default date of medical record access is set at 04.10.2023.

New Patients Joining the Practice

If you are REGISTERING with the practice at the time of this application, please read carefully. When a patient chooses to register at a new GP practice, access to any care record data they had at their old GP practice will no longer be available to them by default. The patients online care record will only show data added from the date of practice registration.

Existing and New Patients

If you wish to request access to medical records that extends past the default dates mentioned above (existing patients 04.10.2023 and new patients date registration) a further application will be required, please ask our reception team for more information.

I wish to access my medical record online in lie with the above default dates and understand and agree with each statement (please tick)

I will be responsible for the security of the information that I access 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 to review.

Signature

PLEASE REMEMBER TO PRINT AND BRING TO THE SURGERY WITH IDENTIFICATION.

FOR PRACTICE USE ONLY

Method of Vouching?

Personal vouchingVouching from information in recordPhoto ID and / or Proof of Address

Access Granted

	PRACTICE MUST COMPLETE
Date Account Created
Date Passphrase Document Sent + Method of issuing
Staff Initials

Patient Details: