Join our GP Surgery

Practice Area

The doctors welcome new patients who live within our practice boundary.
If you would like to check whether you are resident within our Practice area and so eligible to register with us a Practice then please enter your postcode below.

How to Register with Us

Please complete this form if you would like to register with the practice.

Online Registration Form

Step 1 of 2

50%

Title

Mr

Mrs

Miss

Ms

Mx

Dr

Other

NHS Number:  Optional

Surname:

First Names:

Prev Surname:  Optional

Date of Birth

Day

Month

Year

Sex:

Male

Female

Ethnicity:

White – BritishWhite – IrishWhite – TurkishWhite – GreekWhite – KurdishWhite – OtherAsian – IndianBritish IndianAsian – PakistaniBritish PakistaniAsian BangladeshiAsian – OtherBlack – CaribbeanBlack – AfricanBlack – OtherMixed – BritishMixed CaribbeanMixed – AfricanMixed – White & AsianMixed – OtherEthnic – ChineseEthnic – FilipinoEthnic – VietnameseEthic – OtherI do not wish to disclose

First Spoken Language:

Town and Country of Birth:

Address

Street Address Address Line 2 City Post code

Telephone Number

Mobile Number

Email Address

Enter Email Confirm Email

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

Previous Address

Street Address  Optional Address Line 2  Optional City  Optional Post Code  Optional

Name of Doctor while at that address  Optional

Address of previous doctor

Street Address  Optional Address Line 2  Optional City  Optional Post code  Optional

Are you from abroad?

Yes  Optional

No  Optional

Are you in the Armed Forces?

Yes  Optional

No  Optional

If you are from abroad:

Your first address where registered with a GP

Street Address  Optional Address Line 2  Optional City  Optional ZIP / Postal Code  Optional AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country  Optional

If previously resident in UK, date of leaving  Optional

DD slash MM slash YYYY

Date you first came to live in the UK  Optional

DD slash MM slash YYYY

If you are from the Armed Forces:

Address before enlisting

Street Address  Optional Address Line 2  Optional City  Optional ZIP / Postal Code  Optional AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country  Optional

Service or Personnel number  Optional

Enlistment date  Optional

DD slash MM slash YYYY

Discharge date  Optional

DD slash MM slash YYYY

If registering a child under 5:

I wish the child above to be registered with the doctor named overleaf for Child Health Surveillance.  Optional

If you need your doctor to dispense medicines and appliances:

Not all doctors are authorised to dispense medicines.

I live more than 1 mile in a straight line from the nearest chemist.  Optional

I would have serious difficulty in getting them from the chemist.  Optional

NHS Organ Donor registration:

Please tick as appropriate:

Any part of my body  Optional

Or only my:

Kidneys  Optional

Heart  Optional

Liver  Optional

Corneas  Optional

Lungs  Optional

Pancreas  Optional

NHS Blood Donor registration

I would like to join the NHS Blood Donor Register as someone who may be contacted and would be prepared to donate blood.  Optional

Tick here if you have given blood in the last 3 years.  Optional

Emergency Contact

Name:

Relationship:  Optional

Contact Number:

Address

Street Address Address Line 2 City Post Code

---

I have filled in this form on behalf of

MyselfMy childRelativeFriendOther

NEW PATIENT QUESTIONNAIRE

Please answer these questions to the best of your ability and hand this questionnaire into the receptionist. The information will be used to update your personal medical record.

Name

Date Of Birth

Day

Month

Year

Phone Number

Email Address

Height

cm

Weight

kg

What is your smoking status?

Please selectCurrent SmokerEx SmokerNever Smoked

How many cigarettes do you smoke a day?

When did you stop smoking?

DD slash MM slash YYYY

Do you drink Alcohol?

Please selectYesNo

How many units a week do you drink?

How often do you have a drink containing Alcohol?

Please selectNeverMonthly2-4 times monthly2-3 time weekly4+ times weekly

How many units do you drink on a typical day?

Please select01-23-45-67-89+

How often in the last year have you had 6 or more units (Female) or 8 or more units (Male) on a single occasion?

NeverLess than monthlyMonthlyWeeklyDaily / almost daily

Do you have any allergies?

Please selectYes – To a drug/MedicationYes -To something elseNo

Which Drugs/Medication?  Optional

What are your allergies?

Are you on any regular medication?

Please selectYesNo

What medication?

Have you recently come to the U.K. from a country which has a high incidence of tuberculosis e.g. Lithuania or Romania?

Please selectYesNo

If you have had a cough or any unexplained weight loss recently please make an appointment to see one of the doctors.

From which Country?  Optional

Are you a student?

Please selectYesNo

Have you had your MeningitusACWY vaccination?

Please selectYesNo

Section Break

SUMMARY CARE RECORD – your emergency care summary

NHS England has introduced the Summary Care Record, which will be used in emergency care. The record will contain information about any medicines you are taking, allergies you suffer from and any bad reactions to medicines you have had to ensure those caring for you have enough information to treat you safely. Your Summary Care Record will be available to authorised healthcare staff providing you care anywhere in England, but they will ask your permission before they look at it. This means that if you have an accident or become ill, healthcare staff treating you will have immediate access to important information about your health.

GP practices are supporting Summary Care Records and as a patient you have a choice:

Please selectYes I would like a Summary Care Record – you do not need to do anything and a Summary Care Record will be created for you.No I do not want a Summary Care Record – Please ask the receptionist for an opt-out form.

For more information talk to the Patient Advice and Liaison Service (PALS), GP practice staff, visit the website www.nhscarerecords.nhs.uk or telephone the dedicated NHS Summary Care Record Information Line on 0300 123 3020. You can choose not to have a Summary Care Record and you can change your mind at any time by informing your GP practice. If you do nothing we will assume that you are happy with these changes and create a Summary Care Record for you. Children under 16 will automatically have a Summary Care Record created for them unless their parent or guardian chooses to opt them out. If you are the parent or guardian of a child under 16 and feel that they are old enough to understand, then you should make this information available to them.

The Department of Health has asked us to record the ethnic origin, and first language, of all new patients. Please tick the box which most accurately describes you:

White – British

White – Irish

Other White background

White/Black Caribbean

White/Black African

White/Asian

Other mixed background

Chinese

Indian/British Indian

Pakistan/British Pakistan

Bangladesh/British Bangladesh

Other Asian background

Caribbean/British Caribbean

African/British African

Other Black background

Other ethnic background

Prefer not to say

What is your first main spoken language?

Will you need a translator when you see one of our medical team?

Please selectYesNo

THANK YOU FOR TAKING THE TIME TO COMPLETE THIS QUESTIONNAIRE

Overseas Visitors

Those who visit the UK from overseas must pay for their care when they are in England.

In 2015 changes were made to how the NHS charges overseas visitors for healthcare so the NHS does not lose out on income for the services these patients have received.

Temporary Registration

If you’re currently staying with a friend or family member within our GP surgery area for more than 24 hours but less than 3 months, you can ask to register as a temporary resident. You can find more information on registering as a temporary resident on the NHS website.

Registering with a GP as a temporary resident – NHS – NHS (www.nhs.uk)

If you want to register as a temporary resident at our GP surgery, please contact us and we will send you the relevant registration form; or complete the online form below.