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 boundary.

New Patient Registration

New Patient Registration

Patient's Details

Title *
Please use this date format: DD/MM/YYYY.
Sex *
Any responses we send will go to this email address.
Can we contact you by text?
Can we contact you by email?
Preferred method of contact:
Do you live in a residential home?

Previous Details

Please include postcode.

Service Families and Military Veterans

As a practice, we fully support the Armed Forces Covenant. We can only do this if we know our patients connections to the Armed Forces. Please tick the below boxes that apply to you:

Nationality

Please specify the ethnic group you consider you belong to:
Do you speak English?
Do you read English?

If you are from abroad

Registering with the NHS for the first time in the UK
Please use this date format: DD/MM/YYYY.

If you are returning from abroad

Previously been registered with the NHS in the UK
Please use this date format: DD/MM/YYYY.
Please use this date format: DD/MM/YYYY.

Supplementary Questions

I am not ordinarily a resident in the UK

Ordinarily Resident

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.

Please select one of the following statements:

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.

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) ?

If you are visiting from another EEA country and do not hold a current EHIC (or Provisional Replacement Certificate (PRC))/S1, you may be billed for the cost of any treatment received outside of the GP practice, including at a hospital.

EHIC/PRC

Please enter the details from your EHIC or PRC below.

S1 Form

Do you have an S1 Form?
Please give your S1 form to the practice staff.

How will your EHIC/PRC/S1 data be used?

By using your EHIC or PRC for NHS treatment costs your EHIC or PRC data and GP appointment data will be shared with NHS secondary care (hospitals) and NHS Digital solely for the purposes of cost recovery. Your clinical data will not be shared in the cost recovery process.

Your EHIC, PRC or S1 information will be shared with The Department for Work and Pensions for the purpose of recovering your NHS costs from your home country.

Carers

Do you have a carer?
Are you a carer for someone?

Emergency Contact

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

Contacting You

We will use your contact details to send reminders about appointments, reviews and other services which may be of benefit in your medical care.
Do you consent to the surgery sending letters to your home address?
Do you consent to the surgery sending text messages to your mobile?
Do you consent to the surgery sending messages to your email?
Do you consent to the surgery leaving messages on your phone?
We will not leave detailed messages on your phone, but may ask you to contact us or leave a simple message if we do not need to speak to you.

Summary Care Record

If you decide to have a Summary Care Record (SCR), it will contain important information about any medicines you are taking, allergies you suffer from and any bad recations to medicines that you have had. It will also include basic inforrmation about your current diagnoses. 

Giving healthcare staff access to this information can prevent mistakes being made whenh caring for you in an emergency or when your GP practice is closed. Your Summary Care Record will also include your name, address, date of birth and your unique NHS Number to help identifiy you correctly. If you and your GP decide to include more information it can be added, but only with your express permission. 

For more information please call 0300 123 3020 or visit www.nhscarerecords.nhs.uk.

I do not wish to have a Summary Care Record (N.B. This will mean NHS healthcare staff caring for you may not be aware of your current medications, any allergies or reactions to previous medications)

Electronic Prescribing Service (EPS)

The Electronic Prescribing Service (EPS), allows prescribers such as GPs and practice nurses to send prescriptions electronically to a dispenser (such as a pharmacy) of the patient's choice. This makes the prescribing and dispensing process more efficient and convenient for patients and staff. To help achieve this as a practice, we would encourage all patients to opt for electronic prescribing.

Donation Wishes

Do you have a donor card or are you on the organ donor register?
Do you donate blood?

Resuscitation Wishes and Power of Attorney

Do you have a Do not attempt CPR (DNACPR) form in place?
Does anybody hold Lasting Power of Attorney for Health and Welfare for you?

Lifestyle

If you would like advice on managing a healthy weight, please visit https://www.nhs.uk/live-well/ or contact the practice who will be able to direct you to the most appropriate service.

Smoking Status:
Are you interested in advice on how to quit?

Alcohol Consumption

This is one unit of alcohol:

Amount of different types of drink representing one unit of alcohol

And each one of these, is more than one unit:

Amount of different types of drink representing more than one unit of alcohol
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? *