Application for online access to my Detailed Coded Record Name First Last Date of birth Day Month Year Address Street Address Address Line 2 City Postcode Email address Enter Email Confirm Email Contact numberI wish to have access to the following online services (please select all that apply Booking appointments Requesting repeat prescriptions Accessing my detailed coded medical record I wish to access my medical record online and understand and agree with each statement I will be responsible for the security of the information that I see or download Optional If I choose to share my information with anyone else, this is at my own risk Optional If I suspect that my account has been accessed by someone without my agreement, I will contact the practice as soon as possible Optional If I see information in my record that is not about me or is inaccurate, I will contact the practice as soon as possible Optional 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. Optional