Church Farm Close Medical Practice

Access to Summary Records Application Form

If you wish to, you can now use the internet to book appointments with a GP, request repeat prescriptions for any medications you take regularly and look at your medical record online. You can also still use the telephone or call in to the surgery for any of these services as well. It’s your choice.

Please read this leaflet for more information about accessing your summary record

Access your Summary Record Online >>

To register you will need to complete the application form below.  Once this form has been submitted you will need to provide proof of identity by taking this to the surgery you are registered at (Lofthouse Surgery or The Manse Surgery).  You will need to do this before access to online services can be granted.

1Access to Summary Records Application Form

Patient Surname:

Patient Forename:

Date Of Birth:

Address:

Postcode:

Email Address:

Telephone Number:

Mobile Number:

I wish to have access to the following online services (please select all that apply)

Booking Appointments

Requesting Repeat Prescriptions

Accessing My Medical Records

I wish to access my medical record online and understand and agree with each statement

I have read and understood the information leaflet provided by the practicePlease Choose...Yes

I will be responsible for the security of the information that I see or downloadPlease Choose...Yes

If I choose to share my information with anyone else, this is at my own riskPlease Choose...Yes

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

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

---

Privacy Protection

Information submitted through secure forms is used only for the purposes of processing your request. We may be in touch with you in relation to the information submitted.

All Information submitted through secure forms is secured with a private key known only to the GP practice and is accessed over a secure connection by nominated Practice staff. Our practice has a strict confidentiality policy.

This information is not shared with any third party organisations.

This information is retained for up to 28 days.

Learn more about our Privacy Policy and Terms of Use. Should you have any concerns about sending your personal details using the web, please use one of the alternative methods offered by our organisation.

---