Patient Services Registration Form

Last Updated: 29/04/2025

Patient Services Registration Form

Manage Your Healthcare Online: Order prescriptions and schedule GP face-to-face appointments at your convenience.

Registration Process:

1. Complete and submit this form.

2. Check your email: One of our team will send a confirmation email in due course.

3. VITAL FOR ACCOUNT SET UP: REPLY TO OUR EMAIL TO RECEIVE SETUP INSTRUCTIONS.

Eligibility Criteria:

Patients aged 16 and over: Must possess an individual email address to comply with GDPR regulations.

Parents registering children aged 12-15: If the child is capable of making their own decisions, they must have an individual email address. For younger children or those not deemed capable, a parent/carer email may be used.

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)

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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