Travel Vaccinations « Strathpeffer Medical Practice

Under 16s Prescription Orders

Name*
First Last
Date of Birth*
Telephone*
If there are any problems with issuing your prescription, we may call you to let you know.
Medications required*
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Privacy*
- By using this form you agree with the storage and handling of your data by this website.

This is a 3 step process:
(1) Complete this form and submit it to the Surgery
(2) You will receive a phone call from the Surgery in the next few days to verify your account.
(3) You will receive an e-mail from Patient Online Services - please follow the instructions on this e-mail in order to complete your registration.
NB: Your user name cannot contain the @ symbol. Any problems, please look at Help or Contact us at the foot of the Registration page.
First Name*
Last Name*
Date of Birth*
Date Format: DD slash MM slash YYYY
Address*
Preferred Email (not shared)*
Home Phone*
Mobile
I wish to have access to the following online services (tick all that apply):*
- Requesting repeat prescriptions
- Requesting acute prescriptions
I wish to use Online Services. Please read each statement carefully and tick before signing:*
- I have understood the information provided by the Practice
- I will be responsible for the security of the information that I see or download
- If I choose to share my information with anyone else, this is at my own risk
- I will contact the practice as soon as possible if I suspect that my account has been accessed by someone without my agreement
- If I see information in my record that is not about me or is inaccurate, I will contact the practice as soon as possible

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