New Patient Registration Form

We are currently unable to take new patient registrations on-line, however, you can print out the form below and either hand in at the surgery reception or post to the surgery to register as a new patient.

Personal Details:

Mr    Mrs    Miss    Ms    Dr    Other

Surname:………………………………………………

First Name:……………………………………………

Previous Surname(s):……………………………………

Address:………………………………………………

…………………………………………………….

…………………………………………………….

…………………………………………………….

Postcode:……………………………………………..

Home Telephone:………………………………………..

Mobile Telephone:………………………………………

Email:………………………………………………..

Male Female

Date of Birth: …… / …… / ……

Town and Country of Birth……………………………….

Have you ever been registered with a GP in the UK? Yes    No

Name and Address of Previous GP (if applicable):

……………………………………………………..

……………………………………………………..

……………………………………………………..

……………………………………………………..

……………………………………………………..

Your home address while registered with that GP:

……………………………………………………..

……………………………………………………..

……………………………………………………..

……………………………………………………..

Postcode:……………………………………………..

If you are from abroad, the date you first came to the UK:……….

Signature of patient:…………………………………..

Date:…………………………………………………

or

Signature on behalf of patient:………………………….

Date:…………………………………………………

Do you take any regular medication? Yes    No

If you answered yes to the above question, it would be helpful if you could attach details of your medication to your registration form as the GP will only prescribe medication with this information.

Do you have long term illness and/or disability? Yes    No

If you have answered yes to the above question, please make an appointment when registering for a new patient health check.

Do you smoke?

I currently smoke: 1-9 per day   10-19 per day   20-39 per day   40+ per day 

No, I have never smoked    

I used to smoke: Date I quit

How many units of alcohol do you drink in a typical week?

None     1-7      8-15      16-35      36-45      More than 45

What is your approximate height?…………………………

What is your approximate weight?…………………………

Thank you for taking the time to complete this form. The information will help us plan our services better. For more details about how we use your information, please see our practice leaflet which can be found in reception.

Summary Care Record:

A Summary Care Record allows hospitals and other medical services to access your patient summary should you require emergency treatment. It details your medications and allergies. If you would like your information to be available in this way, please ask for a consent form at reception when you bring in your registration form.

Updated March 2017