Online Access Registration Form

Important Information - Please read before completing this form

If you wish, you can now use the internet to book appointments with a GP, request repeat prescriptions for any medication you take regularly and look at your medical record online.

It will be your responsibility to keep your login details and password safe and secure. If you know or suspect that your record has been accessed by someone else then you should change your password immediately.

If you can't do this, we recommend that you contact the practice so that they can remove online access until you are able to reset your password.

If you print out any information from your record, it is also your reponsibility to keep this secure. If you are at all worried about keeping printed copies, then we recommend that you don't make copies at all.

Before you apply for Online Access, there are other things to consider:

Forgotten History - there may be something in your record that you ahve forgotten about and may find upsetting
Abnormal results or bad news - If your GP has given you access to test results or letters, you may see something that you may find upsetting. This could occur before you have spoken to your GP or when the practice is closed and you cannot contact them.
Choosing to share your information with someone - It's your choice whether or not you share information with others - perhaps family members or carers. It remains your choice but also your responsibility that the information remains safe and secure.
Coercion - If you think you may be pressured into revealing details from your patient record against your will, then it is recommended that you do not apply for online access at this time.
Misunderstood Information - Your medical record is designed to be used by clincial professionals to ensure that you receive the best quality care. Some of the information in your record may be highly tecnhnical and not easily understood. If you require further clarification, please contact the practice.. This may require an explanation by a clinician and may not be available immediately.
Information about someone else - If you spot something in the record that is not about you or any other errors, please log out of the system and inform the practice as soon as possible.

Please select the practice location most relevant to this Online Form submission:

Personal Details

Surname

First Name

Date of Birth

Address including postcode

Email Address

Telephone Number

Mobile Number

Access

I wish to have access to the following online services

Booking Appointments

Requesting Repeat Prescriptions

Signature

Email Confirmation

Tick the box if you would like to receive an e-mail confirming the form has been received by Bartholomew Medical Group.

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 Main Surgery • Goole Health Centre, Woodland Avenue, Goole, DN14 6RU.

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.