Request to Access SystmOnline (Adelaide St)

Through our online services you can book appointments, manage your repeat medication and view some areas of your medical record.

Last Updated: 21/05/2020

Register for Online Services

Date of Birth *

Title *

Name *

Address *

Email Address *

I would like to request a password and login to enable me to access SystmOnline to book appointments, request repeat prescriptions and view the summary care record. I understand the importance of keeping my login and password details safe for security purposes. *

I confirm I am the patient named above

I have parental responsibility for patient named above

Signature

Please note that if you are requesting a password and login for a young person under the age of 12 years (this will make you a “Proxy” user). Once this young person reaches 12 years, for the purpose of patient confidentiality your access to their SystmOnline account will automatically be disabled. If you are registering for your own online services you will need to complete this form and return it with photographic ID. If you are registering for a “proxy” user you will need to supply photographic ID and proof that you have parental responsibility for the young person (i.e their birth certificate).

Signature of Patient: *

OR signature on behalf of patient (please state relationship)

Date *

For surgery use only

NOT TO BE COMPLETED BY THE PATIENT

Confirm Pt details on S1

S1 details printed and passed or sent to Pt

Date Completed

Initials

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Request to Access SystmOnline (Adelaide St)

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