Apply for Online Services - Charles Street Surgery


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Online Services Application Form

Once you have completed the form please click 'Submit'.
"*" denotes a required field.

	Personal Details
	Used to identify you as a registered patient.

Surname *

First Name *

Address Line 1 *

Address Line 2 *

Town *

Postcode *

Telephone Number *

Online Services

Terms and Conditions


	I wish to apply for access to on-line services;
Apply for all Services

Repeat Prescription Ordering
			Appointment Booking and Cancellation
		(automatically added to your access when approved)
Personal Information Updating		(automatically added to your access when approved)

TERMS AND CONDITIONS • Where access is refused this will be in writing. A reason will only be given at the discretion of the partners. • Forms submitted are “one per patient”. Acceptance of one member of a family does not imply acceptance of other / further family members. • Patients with a history of none-attendance at pre-booked appointments (without cancelling) will not normally be granted access to on-line appointment booking. • On-line appointments booked are to be cancelled by the patient as soon as it is determined that it is no longer required. • The practice will not allow misuse of the on-line system and will monitor usage by individual patients. Where it is considered that a patient is misusing the system or is acting in a way detrimental to the availability of the appointment system, or other facilities, a warning letter will be issued. Where the situation does not improve, or recurs, access will be removed permanently and without further notice, at the discretion of the Partners. • Repeat prescriptions may only be ordered where these appear on the repeat list, which is provide to patients on the tear-off portion of the last prescription issued. The request must match the repeat list exactly and must be due. Other items ordered or requested using this facility will be not be actioned and no contact will be made with the patient. Prescriptions ordered outside this guideline must be via reception staff. • Personal Information Updating is subject to validation after submission. Patients moving outside the Practice Area will be removed from the practice list in the usual way. • Approved access requests will be notified along with access instructions and a patients’ Code of Practice • Only patients 16 years or over can use this facility. • Passwords and instructions will only be issued to the patient in writing at the registered address, and not to a parent or third party. Where a parent or third party requires access to the system to book an appointment or deal with the offspring of a minor, it is acceptable for the minor to provide the access code direct. • Where a minor requests a change of access code (perhaps to alter access rights) this will be granted at the discretion of the partners.


	I have read and agree to the Terms and Conditions *
	I have read and agree to the Terms and Conditions *