their computer, smartphone or tablet at a time that suits them, anywhere, anytime 24 hours a day, seven days a – week. If you would like to be set up with access to this online system, please complete the below form, and we will contact you shortly with your login details. NAME: DATE OF BIRTH: ADDRESS: LANDLINE TELEPHONE: MOBILE: EMAIL ADDRESS: Please tick the relevant box I GIVE MY CONSENT FOR MY LOGIN YES NO DETAILS TO BE EMAILED TO ME I WOULD PREFER TO COLLECT MY LOGIN Please tick the relevant box DETAILS IN PERSON YES NO I AM AWARE THAT I AM RESPONSIBLE FOR Signature of patient/on behalf of patient THE SECURITY OF THE INFORMATION I SEE OR DOWNLOAD I WILL CONTACT THE PRACTICE AS SOON AS Signature of patient/on behalf of patient POSSIBLE IF I SUSPECT MY ACCOUNT HAS BEEN ACCESSED BY SOMEONE WITHOUT MY AGREEMENT MAY WE USE THE ABOVE CONTACT Please tick the relevant box DETAILS TO EMAIL/TEXT YOU ABOUT NO YES OTHER MATTERS EG. ADVISING YOU OF FLU CLINICS, APPOINTMENT REMINDERS
their computer, smartphone or tablet at a time that suits them, anywhere, anytime – 24 hours a day, seven days a week. If you would like to be set up with access to this online system, please complete the below form, and we will contact you shortly with your login details. NAME: DATE OF BIRTH: ADDRESS: LANDLINE TELEPHONE: MOBILE: EMAIL ADDRESS: I GIVE MY CONSENT FOR MY LOGIN DETAILS TO BE EMAILED TO ME Please tick the relevant box YES NO I WOULD PREFER TO COLLECT MY LOGIN DETAILS IN PERSON Please tick the relevant box YES NO I AM AWARE THAT I AM RESPONSIBLE FOR THE SECURITY OF THE INFORMATION I SEE OR DOWNLOAD Signature of patient/on behalf of patient I WILL CONTACT THE PRACTICE AS SOON AS POSSIBLE IF I SUSPECT MY ACCOUNT HAS BEEN ACCESSED BY SOMEONE WITHOUT MY AGREEMENT Signature of patient/on behalf of patient MAY WE USE THE ABOVE CONTACT DETAILS TO EMAIL/TEXT YOU ABOUT OTHER MATTERS EG. ADVISING YOU OF FLU CLINICS, APPOINTMENT REMINDERS Please tick the relevant box YES NO
Addendum%20Registration%20Form%20Adult.docx