If you live within our Practice Boundary and would like to register with the practice please use this form.

We are trying to avoid patients coming into the surgery where possible. You can verify your I.D through the NHS app, if you have a smartphone, or alternatively you can complete the Register for Online Services form and we will contact you to verify your I.D.

You may still be asked for proof of I.D and address if necessary.

When registering please ensure you include your immunisation history. COVID, Flu, Pneumococcal.

If you are human, leave this field blank.

New Patient Registration

Please complete all fields on this form where applicable. If a field is not applicable please mark as N/A

Patient's Details

Title *

Mr

Mrs

Miss

Ms

Other

Please specify:

Surname: *

Previous Surnames:

First Name(s) *

Date of Birth: *

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

*

Male

Female

Indeterminate

NHS Number:

Home Address: *

Postcode: *

Place of Birth (Town and Country): *

Home Phone Number:

Mobile Phone Number:

Work Phone Number:

Email Address: *

First Language:

Are you happy for us to contact you by Email?

Yes

No

Are you happy for us to contact you by Letter?

Yes

No

Are you happy for us to contact you by Text message?

Yes

No

Please see the attached information regarding communication with patients

Occupation:

Live with:

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

Previous address in UK: *

Please include postcode.

Name and address of previous GP: *

Are you registering for the first time in the UK? *

Yes

No

If you are from abroad

Registering for the first time in the UK

Date you came to live in the UK: *

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

Refugee: *

Yes

No

Asylum Seeker: *

Yes

No

Do you require an interpreter when you see the doctor/nurse? *

Yes

No

If yes, please state in which language: *

Are you returning from abroad? *

Yes

No

If you are returning from abroad

Previously been a resident in the UK

Date you left the UK: *

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

Date you returned to the UK: *

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

Medical / Personal Information

Smoking Status:

Current Smoker

Ex Smoker

Never Smoked

How many do you smoke per day?

Are you interested in Cessation advice?

Yes

No

How many did you smoke per day?

When did you stop?

Our medical and nursing team strongly advise that patients do not smoke. If you would like help in giving up please ask at Reception for information. Alternatively some of the local pharmacists are qualified advisors.

For local information on stopping smoking call the Kick It helpline on 020 3434 2500 or email s.smoking@nhs.net Support materials can be found www.kick-it.org.uk

The NHS smoking helpline can be contacted on 0300 123 1044

Height:

Weight:

Waist Circumference:

Please state how much exercise and what type of exercise you do per week:

Carers

Do you have a carer?

Yes

No

Are you a carer for anyone with a medical condition who would not manage without your help?

Yes

No

Name of carer:

Phone Number:

Address:

Do you give us permission to discuss your medical record with your carer?

Yes

No

Allergies

Do you have any allergies? *

Yes

No

Please specify what you are allergic to, what happens and when you had your first reaction: *

Medical History

Any medical conditions? *

Please include dates or N/A if not applicable.

Any past operations? *

Please include dates or N/A if not applicable.

Any regular medication? *

Please add N/A if not applicable

Sight: *

Good

Poor

Registered Blind

Hearing: *

Good

Poor

Partially Deaf

Deaf

Adult Females only

When was your last cervical smear?

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

Was it done at:

A Previous GP

A Family Planning Clinic

What was the result of the cervical smear?

Have you had a hysterectomy?

Yes

No

What type of hysterectomy?

Do you still have your ovaries?

Yes

No

Pregnancies: dates, type of delivery and child gender:

Family History

Is anyone in your immediate family affected by any of the following:

Asthma

Diabetes

Glaucoma

Blindness

Tuberculosis

Heart Disease

Infectious Disease

Hypertension

Epilepsy

Thyroid Disease

Cancer

Please specify type of cancer:

Other family history illnesses:

Please include dates

Immunisation History

Please list any immunisations/vaccinations you have had: *

Please include dates.

Would like a health check?

Yes

No

We offer confidential routine Chlamydia screening for all patients aged 15-24. Is this something that you would like us to arrange for you?

Yes

No

Would you like a HIV test?

Yes

No