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The process for patients to access various online services offered by keele practice, including booking appointments, requesting repeat prescriptions, and accessing medical records. It includes important information about data security, potential concerns, and the application process.
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Surname
First Name
Date of Birth
Address
Postcode
Email Address
Telephone Numbers
Booking appointments
Requesting repeat prescriptions
Accessing test results, immunisations and problems
Application for online access to my medical record
I have read and understood the information attached to this form
I will be responsible for the security of the information that I see or download
If I choose to share my information with anyone else, this is at my own risk
I will contact the practice as soon as possible if I suspect that my account has been accessed by someone without my agreement
If I see information in my record that is not about me, or is inaccurate I will log out immediately and contact the practice as soon as possible.
Signature Date
For practice use only
Identity verified through
Vouching [ ]
Vouching with information in record [ ]
Photo ID [ ]
Proof [ ]
Name of verifier
Date
Staff name authorising access
Date
Important Information – Please read before return this form
If you wish, you can now use the internet/mobile phone to book appointments with a GP, request
repeat prescriptions for any medications you take regularly, look at test results, immunisations and
medical records all online. Also, you can still call the surgery for any queries regarding the above
services. It’s your choice.
