Register for Online Services

Complete the form below to register your interest in online services. The practice will then contact you either with your account details or to advise if verification of your identity is required (e.g. you presenting the practice with photographic id).

Patient Details

Title

First Names

Surname

Date of BirthDD/MM/YYYY

NHS Number (if known)

Find my NHS Number (opens in new window)

Contact Details

Home Address

Postcode

Telephone

Mobile

E-mail Address

Registration

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

Booking appointments Requesting repeat prescriptions Accessing my medical record

If you would like access to your medical record you need to understand and agree to each of the following statements

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 I will contact the practice as soon as possible if I suspect that my account has been accessed by someone without my agreement If I see information in my record that is not about me or is inaccurate, I will contact the practice as soon as possible

Privacy Protection

Information submitted through secure forms is used only for the purposes of processing your request. We may be in touch with you in relation to the information submitted.

All Information submitted through secure forms is secured with a private key and is accessed over a secure connection by nominated staff. We have a strict confidentiality policy.

This information is not shared with any third party organisations.

This information is retained for up to 28 days.

I consent to my information being used for the purposes described above and wish to submit this online form to St Mary's Surgery • Pinfold Health Centre, Field Road, Bloxwich, WS3 3JP.

Learn more about our Privacy Policy and Terms of Use. Should you have any concerns about sending your personal details using the web, please use one of the alternative methods offered by our organisation.

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