At Elborough Street Surgery we release online bookable GP appointments daily after 6:35pm for the following day. Through patient access you will also have the ability to view your medical records and order repeat medications.

    To register for patient access please complete the application form below. Once we’ve received your application form we will then email you your login details.

    Title

    Date of birth

    First name

    Surname

    Email

    Mobile No.

    I wish to have access to the following online services (please tick all that apply):

    1. Booking appointments YesNo

    2. Requesting repeat prescriptions YesNo

    3. Accessing my medical record YesNo

    I wish to access my medical record online and understand and agree with each statement

    1. I will be responsible for the security of the information that I see or download YesNo

    2. If I choose to share my information with anyone else, this is at my own risk YesNo

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

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

    5. 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. YesNo

    Identification

    Please upload a copy of your driving licence, passport or ID card so as we can verify your identity.

    (File types accepted .png, .jpg and .pdf. Maximum file size 5mb)

    Signature

    Who is signing*

    Please sign in the box below using your mouse or on the screen of your tablet.

    Print name of signatory:

    By clicking submit you confirm that you have read and agreed our terms of service and privacy policy