New Registration
This helps us to provide specific services to you
Your Details
Please note you will also need to provide proof of address and photo ID.
For under 16’s will need full immunisation record.
Gender
Surname
First Name
Previous Name (If Any)
Birth Date
Title
House Number and Street
Town
Postcode
Home Telephone Number
Mobile Number
NHS Number
Main Language
Email Address
Are you a UK/EU Resident?
If no, are you a Visitor in the UK?
Next of Kin Details
Next of Kin (A person we can contact in an emergency)
Next of Kin’s Contact Number
Relationship Status to Next of Kin
Consent to discuss records with Next of Kin
Additional Information:
Previous GP & Address
Previous Home Address
Choice of Chemist Do you agree to us to use this as your nominated pharmacy to send electronic prescriptions to?
Country of birth
Place and country of Birth
Date you entered UK
Ethnicity
More about yourself
Do you need a translator? If so, which language
Have you ever served in Armed Forces?
Do you use any of the following
Sign language
Hearing
Lip reading
Do you have any special circumstances we need to be aware of
Are you homeless?
Refugee?
Asylum seeker?
Learning disability?
Are you housebound?
Are you living in a Care Home?
If you have any of the above, you will need to make an appointment.
Are you a carer? (For children this is only applicable if child has a disability)
Do you look after a sick, disabled, frail relative or friend without payment? Is there a child or young person in the family who helps to provide care or support to another family member. Approximately 10% of the current population are carers.
In order to help us update our Carers Register please spend a few minutes of your time completing this information.
Are you a carer?
Do you have a carer
Are you happy to have your details added to our Carers Register?
Your lifestyle?
Do you exercise? If so, how many hours per week
How much do you sleep? hours per night
What is your current smoking status:
If you need help to quit smoking, please see your local pharmacist for advice.
Do you drink alcohol? (if Yes, please ask reception for the Alcohol Questionnaire form)
Summary care record
A summary care record (SCR) is an electronic summary of key health information. It will hold limited essential information derived initially from your GP record. This will include medication, adverse reactions and allergies. If you wish to know more information regarding the system and the benefits, please ask reception. Alternatively, visit the website: www.nhscarercords.nhs.uk or call?
Your medical information may be shared with other organisations who are involved in your care e.g. district nursing. We will not share identifiable information with anyone that is it not involved unless legally required to.
Are you happy for us to share out your full medical records electronically with other services involved in your care and/or to view (share in)medical records held by other services?
Your medical conditions
Do you suffer or have suffered from any of the following
Please list any medications that you take on a regular basis
If you are on regular medication - bring the prescription or summary from previous GP within a 6 months date.
Please enter the names of any medications you are taking
Women only
This section is to be completed if you are 24 years or above.
Have you had a smear test before?
When was your last smear test done?
Was this normal?
Upload Documents
Proof of Address
Max. size: 32.0 MB
Proof of ID
Max. size: 32.0 MB
Medication List
Max. size: 32.0 MB
Thank you for submitting your details
An administrator will contact you to book your new patient health check Once your registration has been processed