Register as a new Adult Patient Form

Please complete your registration via the link below. Alternatively you can register in any of our surgeries. 

Note will be asked you for details of your previous GP surgery and basic health and medical information, so please have these available.

Once we receive your registration form, it usually takes us up to 3 working days to process. Sometime we may required additional information but we will be in contact if this is the case. 

 

Title
City of birth
Were you born in the UK?
An NHS number is a 10-digit number, like 485 777 3456. If known, please enter your NHS number in the field below. You can find more information on the NHS website
Gender assigned at birth?
Gender identity
Preferred pronouns
Please type NFA if you currently do not have a fixed address
Do you consent to the Practice sending you SMS (Text messages)
Preferred Method of Contact
Name Relationship Contact details
Do you have, or have you ever had, any of the following medical conditions?
Tick all that apply
Cancer type Date of Diagnosis
Family History - does any of your family members suffer from any of the following conditions?
Tick all that apply
Gender Age of diagnosis
How often do you have a drink containing alcohol?
How many units of alcohol do you drink on a typical day when drinking?
How often have you had 6 or more units if female, or 8 or more if male, on a single occasion in the last year?
Do you smoke?
Do you have a healthy diet
Do you currently have a contraceptive device in place?
What is your ethnicity?
Do you require an interpreter?
Are you a refugee?
Are you an Asylum seeker?
Are you an Immigrant?
Were you previously in the forces?
Do you currently have a firearms license?
Do you have a Health Visitor?
Are you a carer by profession?
Are you a carer in receipt of carers allowance?
Are you an unpaid carer for a family member, friend, or partner?
Do you have a carer?
Are you pregnant?
Do you have a health problem or disability that may effect your ability to communicate with the Practice? E.g sight/speech/hearing impairment.
Do you have a repeat prescription?
To include name and postcode
Would you like to be registered for online services?
Do you consent to your GP Practice viewing data that is recorded at other NHS organisations and care services that may care for you?
Do you consent to having a summary care record? (This is a summary of your Medication, Allergies & Adverse Reactions & can only be accessed by a Clinician in England & with your expressed consent. This will help with your care.)
Do you consent to the sharing of data recorded by your GP practice with other NHS organisations that may care for you?
Do you consent to having a SCR with additional information?
Please type your name