Havergal Surgery - Patient Online Registration Form

This form is for patient to request for Access to GP Online services. Once this is processed, you will be contacted with a linkage code. This request can take up to 5 working days.

Proof of ID is needed to process this request. This will need to be emailed to the surgery at nclicb.havergalsurgery@nhs.net

Proof of ID can either by:

Passport
Driving License (Provisional or Full)
Biometric Identity Card

This must be done within 24 hours from submission of this request. Failure to do so will result your request not actioned and will need to be resubmitted.

Last Updated: 13/12/2023

Personal Details

Surname *

First Name *

Date of Birth *

Full address including Postcode *

Email Address *

Contact Number (Mobile Preferred) *

Services Available

Please select all that apply

What Services are you requesting for?

Booking Appointments

Requesting Repeat Presriptions

Accessing My Medical Record

If you selected "Accessing my medical record"

If you are wanting Online Access to your medical record, please review below and agree with the following statements showing you understand each of them. If you do not accept the terms below in relation to access of medical records then we will not be able to process your request.

I (The Patient) will be responsible for the security of the information that I see or download.

I understand

If I (The Patient) choose to share my information with anyone else then this is at my own risk

I understand

I (The Patient) will contact the practice as soon as possible if I suspect that my account has been accessed by someone without my agreement

I understand

If I (The patient) see information in my record that it not about me, or is inaccurate I will log out immediately and contact the practice as soon as possible

I understand

Proof of ID

Proof of ID is needed to process this request. This will need to be emailed to the surgery at nclicb.havergalsurgery@nhs.net

Proof of ID can either by:

Passport
Driving License (Provisional or Full)
Biometric Identity Card

This must be done within 24 hours from submission of this request. Failure to do so will result your request not actioned and will need to be resubmitted.

PLEASE SELECT BELOW THAT YOU UNDERSTAND THAT YOU WILL NEED TO SUBMIT A PROOF OF ID VIA EMAIL FOR THIS REQUEST. THIS MUST BE DONE WITHIN 24 HOURS FROM SUBMISSION OF THIS REQUEST. *

I confirm that I will submit a proof of ID for this request via email within 24 hours of this request

Confirmation of completed form

Please electronically add your name here to confirm the request *

Please add the date of submission of the request *

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Havergal Surgery - Patient Online Registration Form

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