Patient Services Registration Form

Last Updated: 05/12/2023

Patient Services Registration Form

Enjoy the convenience of ordering your prescriptions and booking GP face-to-face appointments at any time of the day or night, wherever you are. Using the Patient Services website on your computer or mobile, you can order prescriptions and book GP face-to-face appointments.

Patients aged 16 and over must have their own individual email address to apply for a Patient Services account. The provisions are in place in order to comply with GDPR regulations.

For parents applying for a Patient Services account for a child aged 12-15, if the child is deemed to have capacity (they are competently able to make their own decisions) then they will be required to have an individual email address. Accounts for younger children, and those not deemed to have capacity can use a parent/carer email.

To register for this online service please complete this form and submit. On receipt of this completed form, we will email the address given to confirm we have the correct email address. On receipt of a reply, we will generate the account set-up letter to enable you to set up your Patient Services Online Account.

TITLE *

Name *

Date of Birth *

Age if under 16?

Phone Number *

Email Address *

Preferred prescription pick-up? *

Ferryburn Pharmacy, South Queensferry (collect daily from surgery)

Queensferry Pharmacy, South Queensferry (collect daily from surgery)

Well Pharmacy, Kirkliston (collect twice a week Tuesday and Thursday)

Omni Pharmacy, Queensferry Road (collect twice a week Tuesday and Friday)

Barnton Pharmacy, Whitehouse Road (collect twice a week Tuesday and Friday)

Boots Pharmacy, The Gyle (collect twice a week Wednesday and Friday)

THIS FORM COLLECTS YOUR NAME, DATE OF BIRTH, EMAIL AND OTHER PERSONAL INFORMATION. THIS IS TO CONFIRM YOU ARE REGISTERED WITH THE PRACTICE, TO ALLOW THE PRACTICE TEAM TO CONTACT YOU AND ALSO TO UPDATE YOUR MEDICAL RECORDS HELD BY THE PRACTICE. PLEASE READ OUR PRIVACY POLICY TO DISCOVER HOW WE PROTECT AND MANAGE YOUR SUBMITTED DATA. *

I consent to the practice collecting and storing my data from this form.

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Patient Services Registration Form

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