New Patient Registration

Patient's details

Title*

First names*

Surname*

Previous surnames*

Please enter N/A if not applicable

Date of birth*

Do you know the NHS number of the person you are registering?*

Yes
No

NHS Number*

Gender*

Male
Female

Who is being registered?*

Please choose the correct age band so we can show you the correct questions below.

Adult over 16 years
Child from 13 to 16 years
Child from 1 to 12 years
Newborn up to 1 year

What is your religion/belief?*

What is your marital status?*

What is your ethnic group?*

Choose one option that best describes your ethnic group or background

I describe my ethnicity as

Town and country of birth*

If you are from abroad

Your first UK address where registered with a GP*

Please enter N/A if not applicable

If previously resident in UK, date of leaving*

Please enter N/A if not applicable

Date you first came to live in the United Kingdom*

Please enter N/A if not applicable

Main language spoken*

Do you require an interpreter?*

We offer double appointments for patient who need a language interpreter or BSL. Please ask at reception when booking an appointment.

No
Yes

Contact details

Home address*

Postcode*

Home telephone number*

Please enter N/A if not applicable

Mobile number*

If the person being registered is 13 years old and above, please provide the mobile number for the responsible adult here and the child's mobile in the box below (it is only visible if the correct age is selected above).

Child's mobile number*

Your email address*

If the person being registered is 13 years old and above, please provide the email address for the responsible adult here and the child's email in the box below (it is only visible if the correct age is selected above).

Enter Email Confirm Email

Child's email address*

Enter Email Confirm Email

Please help us trace your previous medical records by providing the following information

Your previous address in UK*

Please enter N/A if not applicable

Name of previous GP practice while at that address*

Please enter N/A if not applicable

Address of previous GP practice while at that address*

Please enter N/A if not applicable

Next of kin details

Next of Kin full name*

Relationship to you*

Please enter N/A if not applicable

Next of kin telephone number*

Do they have any formal power of attorney for medical care?*

Note, we will only contact this person in case of emergencies, and we will never share confidential information without your consent

Yes
No

Your pharmacy choice

Pharmacy choice*

We are a paper-free surgery, as such our prescriptions are all sent electronically to a pharmacy of your choice. Please let us know which pharmacy you would like prescriptions to be sent to (this can be changed at a future date).

Were you ever registered with an Armed Forces GP

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

Address before enlisting*

Please enter N/A if not applicable

Service or Personnel number*

Please enter N/A if not applicable

Postcode*

Please enter N/A if not applicable

Enlistment date

Discharge date (if applicable)

Footnote: These questions are optional and your answers will not affect your entitlement to register or receive services from the NHS but may improve access to some NHS priority and service charities services.

NHS Organ Donor registration

I want to register my details on the NHS Organ Donor Register as someone whose organs/tissue may be used for transplantation after my death. Please tick the boxes that apply.

Please tell your family you want to be an organ donor. If you do not want to be an organ donor, please visit www.organdonation.nhs.uk or call 0300 123 23 23 to register your decision.

NHS Blood Donor registration

I would like to join the NHS Blood Donor Register as someone who may be contacted and would be prepared to donate blood.

Yes I would like to join the NHS Blood Donor Register
Tick here if you have given blood in the last 3 years

My preferred address for donation is: (only if different from above, e.g. your place of work)

All blood types are needed, especially O negative and B negative. Visit www.blood.co.uk or call 0300 123 23 23.

Non-UK European Health Insurance Card (EHIC), Provisional Replacement Certificate (PRC) details and S1 forms

Complete this section if you live in another EEA country, or have moved to the UK to study or retire, or if you live in the UK but work in another EEA state. Do not complete this section if you have an EHIC card issued by the UK.

Do you have a non-UK EHIC or PRC?*

If you select yes please complete the additional details from your EHIC card that will appear below.

Yes
No

Country code*

Name*

Given names*

Date of birth*

Personal Identification Number*

Identification number of the institution*

Identification number of the card*

Expiry date*

PRC validity period (a) From:*

PRC validity period (b) To:*

S1 form

Please tick this box if you have an S1 (eg you are retiring to the UK or you have been posted here by your employer for work or you live in the UK but work in another EEA member state). Please give your S1 form to practice staff.

Yes I have an S1 form

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.

More about you

Occupation/Job (current/past)*

Please enter N/A if not applicable

Are you retired?*

Yes
No

Are you homeless?*

Yes
No

If you are homeless, may we use the address you registered with for confidential post?*

Yes
No

More about a child or newborn

Name of person with parental responsibility*

Relationship to you*

Name of GP surgery at which they are registered*

Their current home address*

Name and address of school/nursery attended*

School/nursery phone number*

Are you a smoker?*

If yes – we offer smoking cessation services at the practice. Please tick if you would like more information about this.

Yes
Never smoked
Ex-Smoker

Please send me smoking cessation services information*

Yes
No

When did you quit?*

Do you drink alcohol?*

Yes
No

If yes, how many units per week?*

Do you have any allergies? YES (please specify)*

Yes (please specify below)
No

Allergy details*

Carer information

A carer is a person who looks after a relative, friend, or a child with a physical or learning disability (this may include a mental health problem, long-term illness, or frailty). This definition does not include those who are paid carers.

Are you a carer or a young carer?*

Yes
No

Do you have a carer yourself?*

Yes
No

If yes, please give your carer’s name and emergency contact details below*

Do you have a social worker?*

Yes
No

If yes, please provide the name and contact details*

Looked after child/Child in care

A child who has been in the care of their local authority for more than 24 hours is known as a looked after child/child in care.

Are you a looked after child?*

Yes
No

Who are you living with?*

I am living with foster parents
I am living in a residential children's home
I am living in residential settings (e.g. school or secure unit)

If yes, please provide the name and contact details*

Protected characteristics (Equality Act 2010)

All the information given on this form will be kept in the strictest confidence, as part of your medical records.

Please only complete those sections you feel confident in completing or you feel are appropriate for the age of the patient. Please note that this information is helpful to our clinicians to allow them to provide you with the best quality and individualised service that we can offer.

At birth were you described as (please tick one option)

Male
Female
Intersex
Prefer not to say

Which of the following describes how you think of yourself? (please tick one option)

If you choose Other, please describe how you think of yourself in another way.

Male
Female

Have you gone through any part of a process (including thoughts or actions) to change from the sex you were described as at birth to the gender you identify with, or do you intend to? (This could include changing your name, wearing different clothes taking hormones or having any gender reassignment surgery).

Yes
No

Continuing to think about these examples, which of the following options best applies to you? Please tick one option

I am thinking about going through this process
I am currently going through this process
I have already been through this process
I have been through this process, then changed back
None of the above
I prefer not to say

Which of the following describes how you think of yourself? (tick all that apply)

I think of myself in another way as described here

Disability

You're disabled under the Equality Act 2010 if you have a physical or mental impairment that has a 'substantial' and 'long-term' negative effect on your ability to do normal daily activities.

Do you have a disability?

Yes
No

If yes, please describe any special help you require: (e.g. unable to manage stairs, easy-read information, sight/hearing assistance)

Sexual orientation

Patient Participation Group

Our Patient Participation Group (PPG) is chaired by patients and provides the practice with feedback on how we improve our service delivery to meet the needs of our patients. We are an enthusiastic group and are always looking for new members to contribute.

Please tick here if you would like to be added to our PPG mailing list, to receive news and invitations to PPG meetings

Yes please

Newborns and under 5 immunisations

For new-born babies and children aged under 5 years, we require an up-to-date immunisation history. If you do not have this information please tick here*

I have this information
I do not have this information

Consent

Consent*

By submitting your details you are consenting to providing this information for improving our services to you. The data you supply on this form will be securely stored on our website, which is hosted by a third party. We will retain this information on the website for no longer than 7 calendar days. Your contact details will not be sold or shared with a third party. I understand I can revoke this consent at anytime by contacting the practice. Our privacy policy can be viewed on this website.

I agree to the privacy policy.

Comments

This field is for validation purposes and should be left unchanged.

Patient's details

If you are from abroad

Contact details

Please help us trace your previous medical records by providing the following information

Next of kin details

Your pharmacy choice

Were you ever registered with an Armed Forces GP

NHS Organ Donor registration

Non-UK European Health Insurance Card (EHIC), Provisional Replacement Certificate (PRC) details and S1 forms

More about you

More about a child or newborn

Carer information

Looked after child/Child in care

Protected characteristics (Equality Act 2010)

Disability

Sexual orientation

Patient Participation Group

Newborns and under 5 immunisations

Consent

Further info

Company information