Online Services Application Form - The Avenue Medical Centre

Your Details

**If you are requesting access on behalf of a patient, this is known as PROXY access. We would require a signed letter of consent from the patient, ID from both parties and relationship to the patient.**

Your Full Name (including title, Mr, Mrs, Miss etc) *

Date of Birth *

Full Address *

Main Telephone Contact Number *

Email Address (required to provide access linkage key) *

Level of Access Required

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

Booking appointments *

Yes No

Requesting repeat prescriptions *

Yes No

Accessing my medical record *

Yes No

Agreement for Online Access

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

Additional Requirement

To grant you full access to Medical Records the practice will require that you attend in person with Photo ID (Driving License, or Passport etc). This ID will be copied and added to your Medical Records.

FOR PRACTICE USE ONLY

Identity Verified:

Yes No

Authorised By:

Level of Access:

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Online Application Form (Patient Facing Services)

Further Information

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Online Application Form (Patient Facing Services)

Further Information