Register with one of our practices today

To register as a patient with one of our practices, please complete the form below. Please ensure that you specify which practice you wish to register with on the form. Once your chosen practice has confirmed your registration, you will be able to download the NHS App so that you can access all services online.

    Which surgery are your registering for?

    *Which email you are emailing


    Title:
    MrMrsMissMsOther


    Date of birth:
    Gender:
    MaleFemaleIndeterminate


    Can we contact you by text?
    YesNo
    Can we contact you by email?
    YesNo


    Registration Type:

    Ethnicity

    Please specify the ethnic group you consider you belong to:
    White BritishWhite IrishBlack CaribbeanBlack AfricanBlack Caribbean and WhiteBlack African and WhiteIndianPakistaniBangladeshiI do not wish to stateOther ethnic group

    Do you speak English?
    YesNo
    Do you read English?
    YesNo


    Emergency Contact

    Are they your next of kin?
    YesNo


    Do you give us permission to discuss your medical records with them?
    YesNo

    Allergies

    Do you have any allergies?
    YesNo



    Previous Details


    If you are from abroad

    Date you came to live in the UK:


    If you are returning from abroad

    Date you left the UK:
    Date you returned to the UK:

    If you are returning from the armed forces

    Date enlisted:
    Date returned



    Supplementary Questions

    I am not ordinarily a resident in the UK


    European Economic Area (EEA) Country

    For a list of EEA countries visit: www.gov.uk/eu-eea

    Do you live in another EEA country, or have moved to the UK to study or retire, or live in the UK but work in another EEA member state?
    YesNo

    Carers

    Do you have a carer?
    YesNo


    Are you a carer for someone


    Permission to discuss medical information with your carer

    Lifestyle

    Smoking Status



    Do you wish to stop smoking

    *We offer a smoking cessation service please ask for information




    Alcohol questions:

    How often do you have a drink?



    Sight:


    Hearing:



    Medical Background:

    Please provide any current and past medical history:


    Are there any diseases that affect your Parents, Brothers or Sisters (tick all that apply)?


    Which pharmacy would you like your medicine to go to?


    Do you have any specific needs?
    Please detail below any specific needs you have to the Practice can ensure they are identified and accommodated by taking he appropriate action:


    Sharing information

    There may be occasions when it is necessary to share your information with other Health organisations (Hospitals, Health teams, Social care, Out of hours etc.) in order for you to receive the best care and service. There is a formal information sharing agreement in place with these organisations. To help us provide you with the best service only relevant information will be shared with these organisations when necessary.

    Do you consent to relevant information the the surgery record about you being accessible where necessary with other NHS/ Social care services?

    Do you consent for the surgery to view information about you that has been recorded on your record by other service providers where you have received care?

    Where necessary do you consent to wounds being photographed and added to your medical records if deemed appropriate, for the purpose of treatment monitoring?



    Make an enquiry online using this form and one of our team will be in touch. By using this form you agree with the storage and handling of your data by our team.

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    Please register for online services after completing the form