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Online Registration Form.11.2017

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14 views

Online Registration Form.11.2017

Uploaded by

lisaworby
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOCX, PDF, TXT or read online on Scribd
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Nuffield House Doctors Surgery

Online Services Patient Registration Form


To apply for our online service please complete the form below and return it to the Surgery Reception in person, along
with a valid form of photo identification, for example your passport, national identity card or photocard driving
licence. Once your ID has been accepted, the Practice will send you the information that will enable you to
access your online account and set a password. This may take up to 21 working days.

I wishto have access to the following online services (Please indicate which service):
1) Booking & Cancelling Appointment Yes / No
2) Requesting Repeat and Acute Prescriptions Yes / No
3) Allowing Completion of Questionnaires Yes / No
4) Accessing My Detailed Medical Record Yes / No
5) Allow viewing of summary record Yes / No
I wishto access my medical record online and understand and agree with each statement below:
1) I have read and understood the information leaflet provided by the Practice
2) I will be responsible for the security of the information that I see or download
3) If I choose to share my information with anyone else, this is at my own risk
4) If I suspect that my account has been accessed by someone else, this is at my risk
5) If I see information in my record that is not about me or is inaccurate, I will contact the Practice
straight away.
6) If I think that I may come under pressure to give access to someone unwillingly, I will contact the
Practice straight away.

Signature……………………………………………. Date…………………
If you are requesting proxy access to act ON BEHALF of a Nuffield House patient, please complete the separate
Patient Consent Form (available from Nuffield House Reception)

PATIENT DETAILS Please complete in black ink, in BLOCK CAPITALS

Patient Forename(s)

Patient Surname
D D M M Y Y Y Y
Patient Date of Birth / /
Patient Address

Postcode

Patient Email Address


For your security, if possible please avoid
using a shared or business email address
Landline Phone Number (No spaces) Tick last box to
indicate your preferred
Mobile Phone Number contact number

Your confirmation for online services you will receive via your email address.
Indicate below if you DO NOT want to receive SMS messages via your mobile phone.

I am happy to receive SMS messages I do NOT want to receive SMS messages (Delete one)

Please SIGN AND DATE

Staff use only

Patient ID seen Type of ID

Entered on S1 Staff name Date


Task Date Agreed & GP for Access to Detailed Medical Record
About Online services
We offer an online service for our patients, SystmOnline, enabling you to book your
appointments (subject to availability), order your repeat prescriptions and access your
clinical record at your convenience.

If you are a carer for a patient registered at Nuffield House Surgery or acting on their
behalf (including parents) you may still apply for online access even if you are not
registered at Nuffield House yourself. Please contact Reception to request a Patient
Consent Form or contact us at Nuffield.House@NHS.net (this email address is for
SystmOnline administration only and cannot deal with clinical or any other matters).

Online appointment booking


You have the flexibility to book and cancel your appointments from home, at work or any
location with internet access*. You do not need to queue at the Practice or wait on the
telephone, and you can manage your appointments outside Practice opening hours. Not all
appointments are available to book online.

Request your Prescriptions online


Request your authorised repeat and acute prescriptions online by logging into your
account and simply ticking the appropriate boxes. You can review the progress of your
prescriptions and any message that the Practice may have sent to you. Please allow 48hrs
(excluding weekends & Bank Holidays for repeat prescriptions and 72 hours for acute
requests).

Request for access to my medical record on line

* Not accessible from outside the UK

To access the SystmOnline website, go to:

https://systmonline.tpp-uk.com/Login?PracticeId=F81120

or via our website, www.nuffieldhouse.co.uk

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