Online Access Form

Surname *

Forename *

Date of Birth *

Address *

Postcode *

Telephone Number *

Mobile Number *

Email Address

Please specify your preferred method of contact (Email, Text Messaging, Letter ) Please choose ONE option. *

I consent to receiving text messages from Coleridge Medical Centre for the purposes of appointment reminders and information related to your health. *

Yes No

I consent to receiving email messages from Coleridge Medical Centre for the purposes of health promotion, direct health care & practice news *

Yes No

Services Available

With the NHS App, you will already have basic access to ordering medication and booking appointments. The services below will be in addition to this.

Please select your preferences below:

I would like access to my : *

Detail Coded Record

Full Clinical Record

Declaration

I wish to access my medical record online and understand and agree with each statement (please tick all that apply) You can withdraw or change your consent at any time by completing and sending in a new form.

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