HILLHEAD FAMILY PRACTICE 
www.hillheadfamilypractice.co.uk 

Would you like to request repeat prescriptions and book appointments without having to telephone or call into the surgery?    Did you know that you can use the practice web site to do this?

The web site also gives you information about the practice, including opening times, clinics and any changes to services.

You can access our web site at any time, but if you would like to order repeat prescriptions or book appointments on line you will need a login and password set up.

If you would like us to set up a login and password for you, then please complete your information below and pass this into reception.  You will then be contacted with your login details, which you can use from the website.

Name		
Date of Birth		
Email Address	
	
Home Address	

Mobile Number 		
Please note each person registering MUST have their own separate email address
We are unable to register any patient under the age of 16

If you have previously registered for this service and have forgotten your log-in details; please tick this box 
(Please note that we will suspend your existing account and you will be re-registered for this service. You will receive an email asking you to re-register) 

Please leave any notes or comments relating to registration in this box

Signature 		Date		

Please help us keep our records up to date

Do you smoke?					If you are a Current Smoker, are you:
(Please tick as appropriate)
Never Smoked					Light Smoker (1-9 / day)		
Current Smoker					Moderate Smoker (10-19 / day)
Ex-Smoker						Heavy Smoker (20-39 / day)