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Chiltern House Medical Centre

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Patient Access Application Form

Please note, if you wish to register for online services, to access your repeat prescriptions, appointments etc., you are also required to provide evidence of your identification. Identity documentation can be provided online. Once this has been verified, we will issue you with the necessary documentation so you can then register for online services. If you have any further questions please contact the Practice.

Register for Online Services
Enter Email
Confirm Email
Please use format day/month/year e.g. 12/05/1979
I wish to have access to the following online services *
Please tick all that apply

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

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, that 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 *

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.

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