This form is not how you get a portal account — you can make one yourself in a minute. Use this if you would rather somebody rang you, or if there is something they should know first.
Scan your license to fill this in. Hold the back of your driving license up to the camera, or choose a photo of it, and your name and date of birth are read off the barcode - the rest of what it says goes with your request so the office does not have to ask again.
The picture is not saved. It is read once, in this practice's own server, and thrown away.
This does not book an appointment and does not create an account. Somebody at the office reads every one of these.