Register for Online ServicesTo register for online services at Mitcham & Tooting Health, please fill the below form. Are you completing this form on behalf of * Yourself Someone else (e.g. a child or dependent) Name * First and Last Name(s) as appears on your passport First Name Last Name Postcode * The one used to register with your GP Birthdate * MM DD YYYY Sex * As on your medical records Female Male Other Your Phone Number * The practice may use this number to contact you about your request (###) ### #### Email * This email address can be used to contact you about your request. Please be aware, if you have given anyone else access to your email account they may see responses sent to you. Address * Terms & Conditions * I understand that it is my responsibility to keep my details confidential I understand that I can terminate my account at anytime by contacting the surgery, or change my log in details by re-registering and that this form will be kept on my electronic records I understand that my registration will be revoked if I constantly miss or cancel appointments. * * I accept the terms and conditions above Thank you!