Online services account reset request

Please select one of the following: *

I have changed my email address

I have locked my account (by entering my password incorrectly 5 times) and need to reset it

Full Name: *

Phone Number: *

Please specify which number you have provided: *

Mobile Number

Landline/Home Number

Do you consent to us using your mobile number to contact you via SMS messaging? *

Yes

No

Address, including postcode:

Current Email Address: *

Any responses we send will go to this email address.

Previous Email Address: *

This is to verify your existing online services account

Preferred contact method: *

SMS

Email

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

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