Health 365 Registration Form
Name*
First Name Last Name
Email*
example@example.com
Date of Birth*
Day Month Year
Date
We can give you secure access to your personal health information. By registering for this service and Signing below I agree:
- The email address I register is secure & appropriate to receive confidential information.
- I will keep my username & password secure.
- I have permission to register my children under 16 years.
- I agree the Email above is correct.
- I share the family Email and Password.
- I understand there may be a charge for E Scripts & E Consultations.
Signature*
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Should be Empty:

Health 365 Registration Form