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.

NHSFamily doctor services registrationGMS1

Patient's Details

Title *
Gender *

Can we contact you by text?
Can we contact you by email?
Have you previously registered at this surgery?
Is English your main spoken language?
Do you need an interpreter?
Do you live within our catchment area? *
You can find a link to our boundary map at the top of this page.

Ethnic Origin

Please select the ethnic group which you consider you belong to:

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

If you are from abroad

Military

Have you ever served in the Military?

If you are returning from the armed forces

Emergency Contact

Are they your next of kin?

Are you a carer?

Are you a carer?
Are they a patient of ours?

Does somebody care for you?

Does somebody care for you?
Are they a patient of ours?

Height / Weight

(m, ft or in)
(kg, st or lb)

Smoking Status

Do you smoke?

Exercise

Alcohol Consumption

How often do you have a drink that contains alcohol? *
How many standard alcoholic drinks do you have on a typical day when you are drinking? *
How often do you have 6 or more standard drinks on one occasion? *

Additional Questions

Do you use Electronic Prescribing Service?

Please contact your preferred pharmacy to arrange this.

For further information, please contact the surgery or your local pharmacy.

Do you have any additional needs?
eg. Learning disabilities
Are you interested in joining our Patient Participation Group?
If yes, please ensure your email address is included on the previous pages.

Further information is available on our website.

Past Medical History

Have you had any allergies or adverse drug reactions?
Are you on any regular or repeat medication including inhalers, regular creams, or ointments, contraception pills or injections?
Have you ever suffered from:

Adult female patients only

Have you had a hysterectomy?
Do you still have your ovaries?
Have you had a cervical smear?
Was it done:

What happens to my information?

Personal and medical information about patients registered at this Practice are stored electronically and in paper form. Some of the information will be sent to hospital consultants and other health professionals to whom you are referred by your GP in order to provide continued health care and obtain treatment for you.

We sometimes use accredited suppliers for our communication with you, for example when we send recall letters for medication reviews or invitations to our flu clinics. All suppliers we use are checked carefully to ensure they comply with strict confidentiality protocols. To ensure the security of all patient information all staff who have access to your details and medical records are covered by confidentially clauses in their employment contracts and the Data Protection Act and Freedom of Information Act. Our guiding principle is that we hold your records in strict confidence.

I certify that the information I have provided is correct and consent to my personal and medical information being used as stated above.

*

NHS Organ Donor registration

For more information on organ donation, please visit: www.organdonation.nhs.uk

NHS Blood Donor registration

If you would like to join the NHS Blood Donor Register as someone who may be contacted and would
be prepared to donate blood, please visit their website:

www.blood.co.uk or call direct on 0300 123 23 23