To register for our online services you will need to complete this form in full, providing your full name, date of birth, mobile telephone number and email.

We will then issue you a username and password.

Once you are registered you will be able to use the service to:

• Order your repeat prescriptions
• Make an appointment
• Cancel an appointment
• Change your contact details
• Review your medications and known allergies

Register for Online Services - Morden

If you are human, leave this field blank.

Full Name: *

Date of Birth: *

Please use this date format: DD/MM/YYYY.

Phone Number: *

If you do not have a phone number, please put N/A.

Email Address: *

Any responses we send will go to this email address.

Address, including postcode:

Please specify the ethnic group the patient belongs to: * Please select from the following... White: British White: Irish White: Gypsy or Irish Traveller White: any other white background Asian or Asian British - Indian Asian or Asian British - Chinese Asian or Asian British - Pakistani Asian or Asian British - Bangladeshi Asian or Asian British - any other Asian background Asian and Chinese Black or African or Caribbean or Black British - African Black or African or Caribbean or Black British - Caribbean Black or African or Caribbean or Black British - any other black African or Caribbean background Mixed multiple ethnic groups: White and Asian Mixed multiple ethnic groups: White and Black African Mixed multiple ethnic groups: White and Black Caribbean Mixed multiple ethnic groups: any other mixed or multiple ethnic background Other ethnic group Other ethnic group: Arab Decline to state ethnicity

Please specify: *

Terms and Conditions

I understand that it is my responsibility to keep my account secure by keeping my details confidential I understand that I can terminate my account at any time by contacting the surgery, or change my log in details by re-registering and that this form will be kept on my electronic records I understand that my registration will be revoked if I constantly miss or cancel appointments.

*

I accept the terms and conditions stated above