Reception

Enquiries

New Patient Registration

If you would like to register with the practice please use this form.

To register a new patient you will need to live within our practice boundaries.

Patient's Details

Which practice do you wish to register with?
Title
Gender
Do you consent to us leaving messages on this number?
Do you consent to us leaving messages on this number?
Do you consent to receiving text messages to this number?
Do you consent to receive emails to this address?
Marital Status

GMS1

Previous Details

If you are from abroad

Registering with the NHS for the first time in the UK

If you are returning from abroad

Previously been registered with the NHS in the UK

Armed Forces

Please indicate if you have served in the UK Armed Forces and/or been register with a Ministry of Defence GP in the UK or overseas

If you need your doctor to dispense medicines and appliances

Please select one option

Supplementary Questions

Only complete the below if you have ticked 'I am not ordinarily a resident in the UK'.

Anybody in England can register with a GP practice and receive free medical care from that practice.

 

However, if you are not ‘ordinarily resident’ in the UK you may have to pay for NHS treatment outside of the GP practice. Being ordinarily resident broadly means living lawfully in the UK on a properly settled basis for the time being. In most cases, nationals of countries outside the European Economic Area must also have the status of ‘indefinite leave to remain’ in the UK.

 

Some services, such as diagnostic tests of suspected infectious diseases and any treatment of those diseases are free of charge to all people, while some groups who are not ordinarily resident here are exempt from all treatment charges.

 

More information on ordinary residence, exemptions and paying for NHS services can be found in the Visitor and Migrant patient leaflet, available from your GP practice. Alternatively for more information go to www.nhs.uk/visitingengland.

 

You may be asked to provide proof of entitlement in order to receive free NHS treatment outside of the GP practice, otherwise you may be charged for your treatment. Even if you have to pay for a service, you will always be provided with any immediately necessary or urgent treatment, regardless of advance payment.

 

The information you give on this form will be used to assist in identifying your chargeable status, and may be shared, including with NHS secondary care organisations (e.g. hospitals) and NHS Digital, for the purposes of validation, invoicing and cost recovery. You may be contacted on behalf of the NHS to confirm any details you have provided.

I declare that the information I give on this form is correct and complete. I understand that if it is not correct, appropriate action may be taken against me.

 

A parent/guardian should complete the form on behalf of a child under 16.

Please select one of the following statements

European Economic Area (EEA) Country

For a list of EEA countries visit: www.gov.uk/eu-eea

Do you live in another EEA country, or have moved to the UK to study or retire, or live in the UK but work in another EEA member state?
Do you have a non-UK European Health Insurance Card (EHIC) or a Provisional Replacement Certificate (PRC)?

S1 Form

Do you have an S1 Form?

Emergency Contact / Next of Kin

Are they your next of kin?
Do you give us permission to contact them in an emergency?
Do you give us permission to discuss your medical records with them?

Health History

Please ask the receptionist to show you how to use our blood pressure monitor.

Alcohol Consumption

How often do you have a drink containing alcohol?
How many units of alcohol do you drink on a typical day when you are drinking?
How often have you had 6 or more units if female, or 8 or more if male, on a single occasion in the last year?

Smoking

Smoker Status
Are you interested in advice on how to quit?

Exercise

How often do you exercise?

Allergies

Do you have any allergies?

Medical History

Family History

Please select the condition(s) that any family member has or had:

Carers

Do you look after someone that could not manage without you?
Are you being cared for by a relative, friend or child?

Regular Medication

If you are taking regular medication, please provide the surgery with your repeat medication request slip (from your previous surgery) so that the doctors may assess your condition(s) and prescribe for you.

Please note we are unable to prescribe any repeat medication until you have seen a doctor at the surgery.

Are you currently pregnant?

Communication Needs

Do you have any communication needs?

Visual impairment, hearing difficulty, learning disability

Patient Participation Group

What is a Patient Participation Group (PPG)?

A group of registered patients and practice staff who meet frequently to discuss and make decisions

about the practice and how it is able to service the community with improved healthcare services

and facilities.

Would you be interested in joining our Patient Participation Group?
Do you consent to us passing your name and contact details to the chairperson of the Patient Participation Group?

Ethnicity

The Department of Health require us to record the ethnicity and language of every patient registered

with the practice. This information will be used to help plean and deliver services appropriate to

different communities. The categories below have been used accross government since 2001 are

taken from the Department of Health's website.

If English is not your first language, do you speak English?
Please specify the ethnic group you consider you belong to:

Registering For Online Services

Information for New Patients about Your Summary Care Record

Please specify the ethnic group you consider you belong to:

Thanks for submitting!