Request patient access - MyPrivateDoc

Form to request access to content for registered patients
This form is intended to be used only by registered patients of the clinic.
Use it to ask for your patient access details to be sent or re-sent to you.
It collects your name and email address. Once we have checked your details with our patient list, we will send you the access credentials by email.
Check our Privacy Policy for information about how we store, protect and manage your submitted data.
Protecting your data
We are unable to accept form submissions without express consent from you in the checkbox below, as per the new data protection regulations (GDPR).
I am 18 or older*
I am 18 or older and I consent to having the clinic collect my details, store and use my information in the manner described above
- Agree
Name*
Title First Middle Last
Email*
Date of Birth*
DD slash MM slash YYYY
First line of your address*
Your postcode*
Request patient access details by email*
Please send/ re-send my patient access details by email. I confirm that I have secure access to the email I have provided, and that it is my responsibility to keep my patient access details confidential.
Are you human?
Please prove you are human by selecting the Car.

Form to request access to content for registered patients