Only for patients already registered with the practice.

To apply for our online services you will need to complete this form and then visit Brookside Surgery (off Gipsy Lane), bringing  with you two forms of identification. One of these items should include your photograph and the other with your current address (utility & mobile phone bills NOT accepted).

Please allow 3 working days before bringing your ID in.

We will then issue you a username and password.

Once you are registered you will be able to use the service to:

• Access your medical record
• Order your repeat prescriptions
• Make an appointment
• Cancel an appointment
• Review your medications and known allergies

All patients 11+ years will need to register in their own right and visit Brookside Surgery with two forms of ID. Proof of address can be in a parent/carer’s name however a passport or birth certificate will need to be seen for children registering up to the age of 16. You must attend in person and it is advisable that each account is registered to a separate email address. A parent/carer can register on the behalf of any child under 11 years.

Apply for Online Services

If you are human, leave this field blank.

First Name: *

Surname: *

Date of Birth: *

Please use this date format: DD/MM/YYYY.

Phone Number:

Email Address: *

(must be a unique address for those aged 16+)

Address, including postcode:

I understand that I will have access to these online services.

• Booking appointments
• Requesting repeat prescriptions
• Accessing my medical record

*

I wish to access my medical record online and understand and agree with each statement below.

• I will ensure I understand the information provided by the practice when I supply my ID.
• 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

*

My Chosen Pharmacy Is: * Please select a pharmacy... Day Lewis Rankin Pharmacy, 15 Maiden Lane Centre, Earley, Reading RG6 3HD Boots, 5 The Parade, 5 Silverdale Road, Earley, Reading RG6 7NZ Boots, Asda Mall, Earley, Reading RG6 5GA Lloyds Pharmacy (Sainsburys), King Street Lane, Winnersh, Wokingham RG41 5AR Asda Pharmacy, Chalfont Way, Lower Earley, Earley, Reading RG6 5TT Other

Pharmacy Name: *

Pharmacy Address: *

Pharmacy Postcode: *

Patient Representative

Proxy Registration: I am the patient’s representative, and I am registering on behalf of:

Patient's Name:

Relationship to Patient:

Representative's signature:

For Practice Use Only

Patient NHS Number

Practice computer ID number

Identity verified by (initials)

Date

Method

Vouching

Vouching with information in record

Photo ID and proof of residence

Authorised by

Date

Date account created

Date passphrase sent

Level of record access enabled

Prospective

Retrospective

All

Limited parts

Contractual minimum

Notes / explanation