Gray's Inn, Vauxhall, Daleham Gardens, Fortune Green, Old Kent Road

Patient Access Registration Form

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This form is only for REGISTERED PATIENTS. If you are not a patient of the Grays Inn Medical Practice please complete our registration form

Please be aware that the practice policy only allows for patient’s aged 16+ to sign up for Patient Access

Name *

First

Last

Home Address *

Date or Birth *

Email address *

Mobile number *

I wish to have access to the following online services (please tick all that apply): *

I wish to access my medical record online and understand and agree with each statement (tick) *

1. I have read and understood the information leaflet provided by the practice
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. If I suspect that my account has been accessed by someone without my agreement, I will contact the practice as soon as possible
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.

Patient Signature *

I agree to the above Terms and Conditions

Photo ID *

Click or drag a file to this area to upload.

We require an image of your Driver's License, Passport or other Photo ID to verify your identity

After completing the Patient Access registration form,the practice will email you to provide you access to your account login details

Having trouble attaching your photo? Download our form and send it to us with your photo ID at Graysinnmedical@nhs.net