Adult New Patient Registration

PLEASE NOTE THAT IF YOU PLAN TO COME IN TO THE SURGERY WITH YOUR REGISTRATION PAPERWORK, YOU MUST COME IN AFTER 11 AM. THE RECEPTION DESK IS INCREDIBLY BUSY IN THE MORNINGS AND IN ORDER FOR THE REGISTRATION TO BE DONE CORRECTLY, WE NEED TO ENSURE WE ARE ABLE TO FOCUS ON YOUR PAPERWORK. WE WILL NOT TAKE ANY PAPERS BEFORE 11 AM.

After you have completed and submitted the form you must attend the surgery within 5 days with 2 forms of identification (ID). Please note we will not process the registration if you do not come back to the surgery in the week and will discard the documents.

Acceptable Identification; tenancy agreement, mortgage agreement, bank statement, driving licence, passport, birth certificate etc.

For the Donor registration please remember you must register for this yourself. If you fill this on the form it is for our information only. If you want to make sure its on the database you can do this by clicking on the link below. It only takes 2 minutes.

https://www.organdonation.nhs.uk/register-your-decision/register-your-details/

• Patient Details
• Health Information
• Further Information

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Patient's Details

Radio Buttons *

Mr

Mrs

Miss

Ms

Other

I declare to the best of my belief this information is correct. An audit trail is available at the practice for inspection by the HA’s authorised officers and auditors appointed by the Audit Commission.

Surname *

Date of Birth *

Please use this date format: DD/MM/YYYY.

First names *

NHS Number

Previous surnames/Maiden name

Gender

Male

Female

Other

Marital Status

Home address *

Postcode *

Town and country of birth

Mobile Phone Number

Home Phone Number

Email Address *

Are you currently employed?

Full Time

Part Time

Self Employed

Unemployed

Which best describes you:

Retired

Student

Housewife/Househusband/Homemaker

Other

Your first choice of contact method: *

Letter

Email

Text

Phone

Ethnicity

Please select your ethnicity: * White English White Northern Irish White Scottish White Welsh White Irish White Cypriot White Greek White Greek Cypriot White Turkish White Turkish Cypriot White Itialian White Polish White Kosovan White & Black Caribbean White & Black African White & Asian Bangladeshi/British Bangladeshi British Asian Indian/British Indian Black British Black Caribbean Black African Black Nigerian Black Somali Chinese Jewish Iranian Arab Latin American North African Do not wish to disclose Other

What is your second language? (if applicable)

Do you need an interpreter? *

Yes

No

Please select your religion:

Church of England Catholic Other Christian Buddhist Hindu Muslim Sikh Jewish Jehovah's Witness No Religion Prefer not to state

NHS Regulations 2015 Self Declaration *

I am a British resident and entitled to full NHS care

I hold a non-UK issued European Health Insurance Card (EHIC)

I hold an S1 form (entitlement to health care in another European Economic Area country for a limited duration)

Next of Kin & Other Relatives

Next of Kin Full Name:

Relationship to patient:

Contact Phone Number:

Please list other relatives of your home registered with us:

Please include name, relationship & DOB.

Carers

Are you a carer for someone who is ill, frail, disabled, has substance problems or has mental health needs? *

Yes

No

Do you have a carer? *

Yes

No

Carer's Name: *

Phone Number: *

Address: *

Relationship to you:

Are you housebound?

Yes

No

Do you need help with mobility/hearing/speaking?

Wheelchair/hearing aid/braille/lip reading etc.

Medical Records

Please help us trace your previous medical records by providing as much of the following information as possible.

Your previous address in UK *

Name of previous doctor while at that address *

Address of previous doctor *

If you are returning from the armed forces

Address before enlisting

Service or personnel number

Enlistment date

Please use this date format: DD/MM/YYYY.

If you are from abroad

Your first UK address where registered with a GP

If previous resident in UK, date of leaving

Please use this date format: DD/MM/YYYY.

Date you first came to live in UK

Please use this date format: DD/MM/YYYY.