South Street Surgery offers access to certain aspects of your medical records. Use this form to request access to the internet facilities offered by this practice. For security reasons you will need to provide photo evidence of your ID such as a passport or photo driving licence before receiving your access codes. You can only apply for yourself on this form or your child up to their 11th birthday. Once your child reaches the age of 11 your access to their records will cease and they will now have to consent. Further forms will need to be completed by yourself and your child. If access is given this will cease again on the day before they reach 16 and they will then need to apply for their own online access and record viewing. If applying for a child you will need to bring your photo ID and your child’s birth certificate. When the form is completed please hand it in at reception with your ID and you will be issued with your online access ID and instructions.

Patient Online Access – Terms and Conditions

SystmOne Online Services Application Form

Applicant's full name *

Applicant's date of birth *

Full address (including postcode) *

Declaration:

• Please supply me with my/ my child’s (delete one) personal identification number and password details to allow me to access my/ my child’s (delete one) medical records on the internet.
• I understand that I am responsible for securing these details to prevent unauthorised persons from accessing my record online.
• In the event that my security details have been compromised I will inform the practice immediately so that access can be blocked and new passwords issued.
• If at any time I wish to permanently cease internet access I will inform the practice in writing.
• I understand that access for my child will stop on their 11th birthday.
• I also confirm that I have read the terms and conditions and agree to them.

Signed *

I confirm I am the patient/ parent of child mentioned above. Please type your name in the box

Date *