Online Services Registrations - The Villages Medical Group

First Name

Surname

Address

City

State/Province

Zip/Postal

Country

Email

Telephone Number

Mobile Number

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

Booking Appointments

Requesting My Repeat Prescriptions

Limited Access To Parts Of My Medical Record

Access To My Full Detailed/Coded Record

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

I have read and understood the leaflet provided by the practice (At the bottom of this page)

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 inaccurate, I will contact the practice as soon as possible.

How would you like to provide proof of your identity?

Hand in at practice

Upload on this form

File Upload

Maximum upload size: 52.43MB

Signature

Date