Patient Facing Services - Whitburn Group Medical Practice

Patient Facing Services Form

Please complete the form if you are interested in our online patient facing services such as ordering repeat prescriptions and communicating with the practice.

"*" indicates required fields

Name*

Prefix First Last

Date of Birth*

Address*

Street Address Address Line 2 City Post Code

Phone Number*

Enter Email Optional Confirm Email Optional

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

Cancelling / viewing appointments

Requesting repeat prescriptions

Requesting acute prescriptions

Signature*

Date*

Remember me

Yes Optional

Remember my details – We’ll save a copy of your details on your computer and pre-fill them automatically when you next visit this page. Do not select this option if you are using a shared device