Register for Online Services

Complete the form below to express your interest in online services. Alternatively, download the form (DOCX, 21KB) and return the completed form to the surgery.

The practice will then contact you with your account details and will reques : one form of ID such as passport or drivers licence and one form of ID with your home address on such as a recent utility bill or bank statement. Copies can be sent via email or delivered to the practice.

Patient Details

Title

First Names

Surname

Date of BirthDD/MM/YYYY

NHS NumberIf known

Home Address

Postcode

Telephone

Mobile

E-mail Address

Registration

I wish to have access to the following online services (please check all that apply):

Booking appointments

Requesting repeat prescriptions

Summary record access ( medication, allergies and immunisations)

Detailed coded record access ( please note if you are applying for detailed coded records it may take up to 6 months for us

If you would like access to your medical record you need to understand and agree to each of the following statements

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

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 White House Surgery • 1 Cheriton High Street, Folkestone, Kent, CT19 4PU.

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.

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