Register for online services form

If you wish to register for online services, to access your repeat prescriptions etc, please complete this form. Once this has been verified, we will issue you with the necessary documentation so you can then register for online services. Please ensure you also complete the submit your identification online form, we may contact you for additional information or to verify your submitted documentation. Please allow at least 5 working days or more to process your application.

Please remember you must be 16 years of age and over to use this service.

First Name *

Last Name *

Email *

Enter Email

Confirm Email *

Confirm Email

Date of birth *

Please use format day/month/year e.g. 12/05/1979

Phone Number *

You are?

I am the patient

I am the patient’s representative

Signature

Clear

First name *

Last Name *

Relationship to patient *

Signature

Clear

Privacy Policy

This form collects your name, date of birth, email, other personal information and medical details. This is to confirm you are registered with the practice, to allow the practice team to contact you and also to update your medical records held by the practice and our partners in the NHS. Please read our Privacy Policy to discover how we protect and manage your submitted data.

I consent to the practice collecting and storing my data from this form.

Calsayseat Medical Group

Register for online services form

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