request for a my health online account my health online is an online service brought to you from nhs wales. my health online offer



Request for a My Health Online Account
My Health Online is an online service brought to you from NHS Wales.
My Health Online offers patients the convenience to book appointments
using the internet. Depending on your practice you may also be able to
order repeat prescriptions online or change your contact details. If
you wish to register to use My Health Online please fill in the boxes
below. To protect patient confidentiality you must provide documents
so we can make sure you are who you say you are. When you next visit
your practice please return this form and provide identification,
preferably photo ID (e.g. driving licence or passport).
Request for a My Health Online Account
Please set up a My Health Online Account and issue me with a letter
containing my account details.
Full Name
Date of Birth
Address
Phone Number
Email
Mobile Number
Preferred language (delete as appropriate)
Welsh
English
Signature
Date
The following sections to be completed by practice staff.
Practice Checklist
The following checks should be completed before a patient can receive
access to My Health Online.
1.
P atient’s identity verified by document
Details of documents checked and added to the GP system
…………………………………………………………………………………………………………………………
2.
P atient’s name and date of birth checked on this form and
updated on the clinical system. (if necessary)
3.
P atient’s preferred language and contact details updated
on the clinical system. (if necessary)
4.
P atient Guide provided to patient
5.
A dvise patients to register their online account over the
next 24 – 48 hours

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