I wish to be able to access certain services at the Oaks medical practice via the internet or with a fax machine.

In understand that I will be issued a PIN number to use when contacting the surgery via e-mail or on a fax machine. I must quote this number and my full name / date of birth and address when using this method.

I understand that if I ask for information about my care that Fax machines and E-mail are not fully secure and that it is possible that people other than myself might view it.

I understand that the practice require my consent to send information about me via email or fax machines and I hereby give this consent to the practice to send this information to me if I present my PIN number.

Services this covers are:

• Ordering repeat prescriptions
• Asking about blood results
• Enquiring about available appointments

By signing below I state I have read the above and understand it and give full consent to the practice to respond to my online or FAX requests.

Name:

Address:

Date of Birth:

PIN number:

Signature:

Witness by :