Address: Email: Mobile Phone Number: I confirm I am the patient named above/OR I have parental responsibility for patient named above (please delete where appropriate). I would like to request a password and login to enable me to access SystmOnline to book appointments, request repeat prescriptions, view my coded medical record and my summary care record. I understand the importance of keeping my log in and password details safe for security purposes. Please note that if you are requesting a password and login for a young person under the age of 11 years (this will make you a user). Once this young person reaches 11 years of age, for the purpose of patient “Proxy” confidentiality your access to their SystmOnline account will automatically be disabled. If you are registering for your own online services you will need to complete this form and return it with photographic ID. If you are registering for a user you will need to supply photographic ID and proof that “proxy” you have parental responsibility for the young person (i.e. their birth certificate) I wish to have access to the following online services (please tick all that Booking appointments Requesting repeat medications Accessing my Summary Care Record I consent to my username and password for accessing my online services be sent to me by post once the registration process is complete (please tick this box to show your consent) Signature Patient Signature/Signature on behalf of patient If you are not the patient please state your relationship to the patient Date SHARING YOUR NHS PATIENT DATA Information sharing in the NHS is subject to rigorous regulation and governance to ensure your full identifiable and personal medical data is kept confidential and only ever seen by carefully vetted doctors, nurses and administrative staff responsible for overseeing your care. With the development of information technology the NHS will increasingly be sharing key information from your GP medical notes with Out of Hours GP Services, Hospital A&E Units, Community Hospitals, and Community Nurses all of whom may at various times in your life be looking after you.
Address: Email: Mobile Phone Number: I confirm I am the patient named above/OR I have parental responsibility for patient named above (please delete where appropriate). I would like to request a password and login to enable me to access SystmOnline to book appointments, request repeat prescriptions, view my coded medical record and my summary care record. I understand the importance of keeping my log in and password details safe for security purposes. Please note that if you are requesting a password and login for a young person under the age of 11 years (this will make you a “Proxy” user). Once this young person reaches 11 years of age, for the purpose of patient confidentiality your access to their SystmOnline account will automatically be disabled. If you are registering for your own online services you will need to complete this form and return it with photographic ID. If you are registering for a “proxy” user you will need to supply photographic ID and proof that you have parental responsibility for the young person (i.e. their birth certificate) I wish to have access to the following online services (please tick all that Booking appointments Requesting repeat medications Accessing my Summary Care Record I consent to my username and password for accessing my online services be sent to me by post once the registration process is complete (please tick this box to show your consent) Signature Patient Signature/Signature on behalf of patient If you are not the patient please state your relationship to the patient Date SHARING YOUR NHS PATIENT DATA Information sharing in the NHS is subject to rigorous regulation and governance to ensure your full identifiable and personal medical data is kept confidential and only ever seen by carefully vetted doctors, nurses and administrative staff responsible for overseeing your care. With the development of information technology the NHS will increasingly be sharing key information from your GP medical notes with Out of Hours GP Services, Hospital A&E Units, Community Hospitals, and Community Nurses all of whom may at various times in your life be looking after you.
NEW%20REGISTRATIONS%20FORM%20-%20BHG%20-%20Adult.docx