Online Access Application Form: Covid-19 Adaptation

This form should only be used to sign up for online access with Patient Access for yourself. You will need to complete a proxy access form to gain access for your children or another person.

We will send your login credentials after successful validation of your application.

Once you are registered you will be able to use the service to:

Order repeat prescriptions
Make appointments
Cancel an appointment
Update your contact details
Review your medications and known allergies

All questions marked with an asterisk * are required.

Online Access Application

Patient Details

First Name *

Last Name *

Email *

Enter Email

Confirm Email *

Confirm Email

Date of birth *

Please use format day/month/year e.g. 12/05/1979

NHS Number

How can we contact you? *

Landline Phone Number

Mobile Phone Number

Please select all methods we can use if we need to get in touch with you.

Landline Number *

Mobile Number *

Patient Responsibilities

Please confirm you understand your responsibilities when using online services.

I have read and understand the information provided by the practice

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

If I suspect that my account has been accessed by someone without my agreement, I will contact the practice as soon as possible

If I see information in my record that is not about me or is inaccurate, I will contact the practice as soon as possible

If I think that I may come under pressure to give access to someone else unwillingly, I will contact the practice as soon as possible

Identity Check

Normally patients would be required to bring Photo ID to the practice in order to confirm identity
but during the Covid-19 pandemic we will be verifying identity from your records.

Please can you answer as many of the following questions as you are able to help us verify your identity:

When was the last time you came to the surgery for an appointment - please estimate date if you do not know

What was the reason for your last appointment at the surgery

What was the reason for your most recent referral to hospital

If you are on long term medications, please name one medicine that you requested last time you ordered

What year did you register with the Practice

Privacy Policy

This form collects your name, date of birth, email, other personal information and medical details. This is to confirm you are registered with the practice, to allow the practice team to contact you and also to update your medical records held by the practice and our partners in the NHS. Please read our Privacy Policy to discover how we protect and manage your submitted data.

I consent to the practice collecting and storing my data from this form.

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Moorside Clinic

7-9 Moorside Road
BR1 5EP

Chinbrook Surgery

32 Chinbrook Road
SE12 9TH

Marvels Lane Surgery

37 Marvels Lane
SE12 9PN

Boundfield Medical Practice

103 Boundfield Road
SE6 1PG

ICO Health Group

Online Access Application Form: Covid-19 Adaptation

Patient Details

Access Requirements

Patient Responsibilities

Identity Check

Privacy Policy

Health A-Z

Live Well

Medicines Guide

Care & Support

Moorside Clinic

Chinbrook Surgery

Marvels Lane Surgery

Boundfield Medical Practice

Online Access Application Form: Covid-19 Adaptation

Patient Details

Access Requirements

Patient Responsibilities

Identity Check

Privacy Policy

Health A-Z

Live Well

Medicines Guide

Care & Support

Moorside Clinic

Chinbrook Surgery

Marvels Lane Surgery

Boundfield Medical Practice

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