Pennine Surgery, Featherstall Road, Littleborough, OL15 8HF  
Tel: 01706 374990  www.penninesurgery.co.uk
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EMIS Online Patient Access Registration Form

One form should be completed for each family member. All persons over the age of 16 should sign their own form. Thank you.

Surname	Forename 	
Address

Postcode 	Email Address	
Telephone Number 	Mobile Number 

I wish to have access to the following on-line services (please tick all that apply):

 1. Booking appointments	

2. Requesting repeat prescriptions 

		
3. Accessing my medical record (coded information only) 
Before selecting this option please read the information overleaf.  The application process will take up to 14 days.	

1. I have read and understood the information leaflet provided by the practice and the terms and conditions of use overleaf. 	

2. I will be responsible for the security of the information that I see or download.	

3. If I choose to share my information with anyone else, this is at my own risk.	

4. I will contact the practice as soon as possible if I suspect that my account has been accessed by someone without my agreement. 	

5. If I see information in my record that is not about me or is inaccurate, I will contact the practice as soon as possible. 	

 Signature 	

	Date 	

For Practice Use Only 
Patient NHS Number 	Practice Computer ID Number 	
Identity Verified BY
(initials) 	Date 	Vouching
Photo ID 
Proof of Residence 
	
Authorised by	Date 	
Date Account Created 	Read Code Added (912P	
Notes/Explanation 

Terms and Conditions of Use 

1. Registration forms will only be given to patients on an individual basis. Registration for other family members may be requested, and the relevant documentation will be produced and forwarded directly to the patient via the postal system. This does not apply to children aged under 16. 

2. Registration and identity verification must be authorised and carried out by a member of the Practice Staff. 

3. Patients must provide two forms of identification to confirm their identity. At least one should contain a photo of the individual. Any two of the following documents are acceptable: passport, driving license, or a bank statement. 

4. Patients decide their own password and it is their responsibility to keep this secure. If the password is disclosed to another party to book appointments on the patient’s behalf, this remains the responsibility of the named patient. 

5. As the patient I understand that if I share my access details with anyone else, I am at risk of sharing personal confidential information. 

6. If a patient thinks they may be pressured into revealing details from their patient record to someone else against their will, it is best not to register for access at this time. 

7. Patients are asked to use the on-line booking system sensibly and with consideration for others needing appointments. Only two appointments may be booked at one time. 

8. Please remember to cancel appointments with reasonable notice, so that they can be offered to others. Patients who repeatedly cancel appointments, without reasonable notice and without good reason, will have their access stopped. 

9. Patients wanting access to their medical record and test results should be aware that they may see something that they may find upsetting. This may occur before they have spoken to a doctor or while the surgery is closed. 

10. Patients are asked if they spot something in their record that is not about them or any other errors; they should log out of the system immediately and contact the practice as soon as possible. 

11. The practice will monitor usage of the system. If a patient is found to be abusing this practice policy, registration will be cancelled and the patient informed of the reason why. 

12. The Doctors at Hopwood Medical Centre do not have control of the Emis Access site/patient.co.uk website and will not accept responsibility for any operational problems with that site. We are happy to pass on to Emis any problems experienced on the site. 

13. In the event of operational problems with the Emis Access site, please contact the Practice by phone or in person to book an appointment. If you require a prescription you will have to drop in a medication request form or the right hand side of your last prescription. 

14. Patients will be expected to give 48 working hours’ notice for the processing of repeat prescriptions. 

Please ensure you have read and understood the Terms and Conditions of the EMIS Online Patient Access service before completing the registration form overleaf.