Online Services Account Reset Request

If you have an existing online services account and need to change your email address or reset your account (if your password was entered incorrectly five times), please submit this form.

Online Services Account Reset Request

If you are human, leave this field blank.

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

Patient Details

Full Name: *

Date of Birth: *

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

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

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