Online Services Application (Patients over 13 yrs old) Application for patients over the age of 13 years old Name First Last Date of Birth DD slash MM slash YYYY Address Street Address Address Line 2 City Postcode Email Address Telephone NumberMobile Number OptionalWe are pleased to offer you the facility to use “SystmOnline” which provides internet services for patients over the age of 13 years to: • View, book or cancel doctor appointments • View a list of your current medication and send repeat prescription requests • View a summary of your medical records and the detailed coded entries • View pathology results Please note that the full clinical record is not currently available.I wish to access my medical record online and understand and agree with each statement (tick) 1. I have read and understood the patient Guidance notes for Systmonline and User Policy 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 6. If I think that I may come under pressure to give access to someone else unwillingly I will contact the practice as soon as possible. SignatureDate DD slash MM slash YYYY Please note that this could take up to 3 working days to organise.