Adult New Patient Registration

Completing this form is the first step to registering with the practice.

We are signed up to the Safe Surgeries pledge.

Please note that we are only able to accept new patients who currently live within our practice boundary.

Please remember to tick the box on the form if you are a carer for someone.

Carers are people who, without payment, provide help and support to a family member, friend or neighbour who cannot manage on their own due to physical or mental illness, disability, substance misuse or frailty brought on by old age.

Caring roles can include administering medication, lifting and handling, personal or
emotional care. Carers should not be confused with paid care workers, care assistants
or with volunteer care workers.

• 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.