Register for Online Services "*" indicates required fields Register for Online ServicesTo register for an online services account for appointment booking and prescription requests, you will need to complete and submit this form. We will then issue your username and password. If you have forgotten your password or are locked out please do not use this form but contact Reception.Name* First Last Date of Birth* MM slash DD slash YYYY Phone*Email* Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Please confirm you are a registered patient at Lodge Surgery, Lodge Road, Chippenham, Wiltshire. If not, please contact your own GP practice.* Yes I am a registered patient at Lodge Surgery, Lodge Road, Chippenham, Wiltshire I would like access to my online services account to manage appointments and prescription requests.* Yes No 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 consent to the practice collecting and storing my data from this form. Consent*THIS FORM COLLECTS YOUR NAME, DATE OF BIRTH, EMAIL, OTHER PERSONAL INFORMATION AND MEDICAL DETAILS. 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 AND OUR PARTNERS IN THE NHS. 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.