New Patient Registration

If you would like to register with the practice please use this form.

To register a new patient you will need to live within our practice boundary.

Please discuss with a Health Professional if you have any concerns that you may have contracted a blood born virus, ie Hepatitis B or C or HIV. This can occur through unprotected intercourse, injecting drugs or sharing an infected persons personal items eg. razors, toothbrushes or unsterile tattooing, or from blood transfusions in the UK before September 1991. Please also advise of any medical or dental treatment, including blood transfusions, received in foreign countries, where the medical equipment may not have been properly sterilised.

Our practice uses the following providers and functionality for our text messaging services:

MJOG

  • Appointment reminders
  • Ask patient to contact surgery
  • Health messages
  • Invite to make an appointment
  • Request for video consultation

AccuRx

  • Appointment reminders
  • Ask patient to contact surgery
  • Health messages
  • Invite to make an appointment
  • Request for video consultation
  • Request images
  • SenD MED3 certificated
New Patient Registration

Patient's Details

Title *
Please use this date format: DD/MM/YYYY.
Sex *
Please supply your NHS number where possible. This can be found on any NHS correspondence.
Any responses we send will go to this email address.

Please be aware that if you share a mobile number, the other person may see messages about your health.

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

Have you been advised that you are at high risk (clinically extremely vulnerable) from coronavirus (COVID-19)? *

Please provide a copy of your letter. This can be uploaded at the end of the form or it can be sent to the practice.

Ethnicity

Please specify the ethnic group you consider you belong to: *
Do you speak English?
Do you read English?
Do you have any communication difficulties?

Communication Needs

What is the best way to contact you?

In line with the Accessible Information Standard this information will be accepted as formal notification of your communication preferences.

Emergency Contact

Are they your next of kin?
Do you give us permission to discuss your medical records with them?

Next of Kin

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

Allergies

Do you have any allergies?

Previous Details

Do you have a previous UK address? *
Have you previously registered with a UK GP? *

If you are from abroad

Registering with the NHS for the first time in the UK
Please use this date format: DD/MM/YYYY.

If you are returning from abroad

Previously been registered with the NHS in the UK
Please use this date format: DD/MM/YYYY.
Please use this date format: DD/MM/YYYY.

If you are from the Armed Forces

Are you a military veteran?
Veterans include anyone who has served for at least one day in the Armed Forces (Regular or Reserve)
Are you happy for us to record this on your medical record?

As you are a military veteran, you can receive priority treatment for any condition likely to relate to your military service.

Supplementary Questions

I am not ordinarily a resident in the UK

Ordinarily Resident

Anybody in England can register with a GP practice and receive free medical care from that practice.

However, if you are not ‘ordinarily resident’ in the UK you may have to pay for NHS treatment outside of the GP practice. Being ordinarily resident broadly means living lawfully in the UK on a properly settled basis for the time being. In most cases, nationals of countries outside the European Economic Area must also have the status of ‘indefinite leave to remain’ in the UK.

Some services, such as diagnostic tests of suspected infectious diseases and any treatment of those diseases are free of charge to all people, while some groups who are not ordinarily resident here are exempt from all treatment charges.

More information on ordinary residence, exemptions and paying for NHS services can be found in the Visitor and Migrant patient leaflet, available from your GP practice. Alternatively, for more information go to www.nhs.uk/visiting-or-moving-to-england.

You may be asked to provide proof of entitlement in order to receive free NHS treatment outside of the GP practice, otherwise, you may be charged for your treatment. Even if you have to pay for a service, you will always be provided with any immediately necessary or urgent treatment, regardless of advance payment.

The information you give on this form will be used to assist in identifying your chargeable status, and may be shared, including with NHS secondary care organisations (e.g. hospitals) and NHS Digital, for the purposes of validation, invoicing and cost recovery. You may be contacted on behalf of the NHS to confirm any details you have provided.

Please select one of the following statements:

I declare that the information I give on this form is correct and complete. I understand that if it is not correct, appropriate
action may be taken against me.

A parent/guardian should complete the form on behalf of a child under 16.

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?
Do you have a non-UK European Health Insurance Card (EHIC) or a Provisional Replacement Certificate (PRC) ?

If you are visiting from another EEA country and do not hold a current EHIC (or Provisional Replacement Certificate (PRC))/S1, you may be billed for the cost of any treatment received outside of the GP practice, including at a hospital.

EHIC/PRC

Please enter the details from your EHIC or PRC below.

S1 Form

Do you have an S1 Form?
Please give your S1 form to the practice staff.

How will your EHIC/PRC/S1 data be used?

By using your EHIC or PRC for NHS treatment costs your EHIC or PRC data and GP appointment data will be shared with NHS secondary care (hospitals) and NHS Digital solely for the purposes of cost recovery. Your clinical data will not be shared in the cost recovery process.

Your EHIC, PRC or S1 information will be shared with The Department for Work and Pensions for the purpose of recovering your NHS costs from your home country.

Carers

Do you have a carer?
Are you a carer for someone?
Are you a carer for anybody that, due to a chronic physical or mental illness, is unable to fully look after themselves (this may be an unpaid role)?

You will receive a carer registration form in the post.

Do you give us permission to discuss your medical record with your carer?