For practice use only: Usual GP authorisation only if level 2 access is Date: requested usual GP signature: – Level of record access enabled: Entries reviewed by: (for Level 2 access only) Level 1 Booking appointments and requesting – repeat medication  Level 2 Online medical records Readcode XaE42 added –   Account created by: Date: Identification documents: (Practice use only) Driving License Number: Date of issue: Date of expiry: Passport Number: Date of issue: Bank Statement Bank Name: Date of issue: Utility Bill At the discretion of the Practice Manager Elly Potter: – Signed: Form taken in by: (Receptionist)
For practice use only: Usual GP authorisation only if level 2 access is requested – usual GP signature: Date: Level of record access enabled: Level 1 – Booking appointments and requesting repeat medication  Level 2 – Online medical records  Entries reviewed by: (for Level 2 access only) Readcode XaE42 added  Account created by: Date: Identification documents: (Practice use only) Driving License Number: Date of issue: Date of expiry: Passport Number: Date of issue: Bank Statement Bank Name: Date of issue: Utility Bill At the discretion of the Practice Manager – Elly Potter: Signed: Form taken in by: (Receptionist)
PatientOnline-registration_form.docx