Application for online access to my medical record

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

I have read and understood the information leaflet (see - 'New Patients' section on the website) *

yes

I will be responsible for the security of the information that I see or download *

yes

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

yes

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

yes

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

yes

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 *

yes

Signiture *

Date *

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