I confirm I/the patient have ensured I have 4 weeks supply of medication before registering. We cannot supply immediate medication upon registration(Required)
Patient's details Title(Required) Date of birth(Required) Do you know the NHS number of the person you are registering?(Required) Gender(Required)
Please help us trace your previous medical records by providing the following information Your previous address in UK(Required) Please enter N/A if not applicable
If you are from abroad Your first UK address where registered with a GP(Required) Please enter N/A if not applicable
Were you ever registered with an Armed Forces GP Please indicate if you have served in the UK Armed Forces and/or been registered with a Ministry of Defence GP in the UK or overseas(Required) Address before enlisting(Required) Please enter N/A if not applicable
Enlistment date Discharge date (if applicable) Footnote: These questions are optional and your answers will not affect your entitlement to register or receive services from the NHS but may improve access to some NHS priority and service charities services.
Non-UK European Health Insurance Card (EHIC), Provisional Replacement Certificate (PRC) details and S1 forms Complete this section if you live in another EEA country, or have moved to the UK to study or retire, or if you live in the UK but work in another EEA state. Do not complete this section if you have an EHIC card issued by the UK.
Do you have a non-UK EHIC or PRC?(Required) If you select yes please complete the additional details from your EHIC card that will appear below.
Date of birth(Required) Expiry date(Required) PRC validity period (a) From:(Required) PRC validity period (b) To:(Required) S1 form Please tick this box if you have an S1 (eg you are retiring to the UK or you have been posted here by your employer for work or you live in the UK but work in another EEA member state). Please give your S1 form to practice staff.
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.
More about who you are registering Who is being registered?(Required) Please choose the correct age band so we can show you the correct questions below.
Email Are you homeless?(Required) Are you retired?(Required) If you are homeless, may we use the address you registered with for confidential post?(Required) Do you have a registered power of attorney?(Required) Note, we will only contact this person in case of emergencies, and we will never share confidential information without your consent.
More about a child or newborn Their current home address(Required)
Do you require an interpreter?(Required) We offer double appointments for patients who need a language interpreter or BSL. Please ask at reception when booking an appointment.
Are you a smoker?(Required) If yes – we offer smoking cessation services at the practice. Please tick if you would like more information about this.
Please send me smoking cessation services information(Required) Do you drink alcohol?(Required) Do you have any allergies? YES (please specify)(Required) Allergy details(Required)
Please list below your current repeat medication(Required)
Do you currently have or had any of the following?(Required)
Family history Are you adopted?(Required) Does anyone in your family have or previously had any of the following(Required)
Females only Please let us know the date of your last cervical screening (smear) test (if you are over 25 years old)
Have you had a hysterectomy?(Required) Do you have a coil or implant?(Required) Carer information A carer is a person who looks after a relative, friend, or a child with a physical or learning disability (this may include a mental health problem, long-term illness, or frailty). This definition does not include those who are paid carers.
Are you a carer or a young carer?(Required) Do you have a carer yourself?(Required) Are you a looked after child?(Required) Who are you living with?(Required) If yes, please provide the name and contact details(Required)
Protected characteristics (Equality Act 2010) All the information given on this form will be kept in the strictest confidence, as part of your medical records.
Please only complete those sections you feel confident in completing or you feel are appropriate for the age of the patient. Please note that this information is helpful to our clinicians to allow them to provide you with the best quality and individualised service that we can offer.
At birth were you described as (please tick one option) Which of the following describes how you think of yourself? (please tick one option) If you choose Other, please describe how you think of yourself in another way.
Have you gone through any part of a process (including thoughts or actions) to change from the sex you were described as at birth to the gender you identify with, or do you intend to? (This could include changing your name, wearing different clothes taking hormones or having any gender reassignment surgery). Continuing to think about these examples, which of the following options best applies to you? Please tick one option Which of the following describes how you think of yourself? (tick all that apply) I think of myself in another way as described here
Ethnicity What is your ethnic group? Choose one option that best describes your ethnic group or background
1. White - English/Welsh/Scottish/Northern Irish/British 2. White - Irish 3. White - Gypsy or Irish Traveller 4. Any other White background (please describe below) 5. White and Black Caribbean 6. White and Black African 7. White and Asian 8. Any other Mixed/Multiple ethnic background (please describe below) 9. Indian 10. Pakistani 11. Bangladeshi 12. Chinese 13. Any other Asian background (please describe below) 14. African 15. Caribbean 16. Any other Black/African/Caribbean background (please describe below) 17. Arab 18. Any other ethnic group (please describe below)
Disability You're disabled under the Equality Act 2010 if you have a physical or mental impairment that has a 'substantial' and 'long-term' negative effect on your ability to do normal daily activities.
Do you have a disability?(Required) Do you need information communicated to you in a specific format?(Required)
PPG Our Patient Participation Group (PPG) is chaired by patients and provides the practice with feedback on how we improve our service delivery to meet the needs of our patients. We are an enthusiastic group and are always looking for new members to contribute.
Please tick here if you would like to be added to our PPG mailing list, to receive news and invitations to PPG meetings Childhood vaccinations For new-born babies and children aged under 5 years, we require an up-to-date immunisation history.
Please give a date when the child received their 8 week vaccinations Primary Imms - 8 weeks (usual)
First 6-in-1 vaccine DTap/IPV/Hib/HepB Vaccination
First MenB First meningitis B vaccination
First Rotavirus vaccine Please give a date when the child received their 12 week vaccinations Primary Imms - 12 weeks (usual)
Second 6-in-1 vaccine Second DTap/IPV/Hib/HepB Vaccination
First Pneumococcal vaccine Pneumococcal (PCV) vaccine,
Second Rotavirus vaccine Rotavirus vaccine (2nd dose)
Please give a date when the child received their 16 week vaccinations Primary Imms - 16
weeks (usual)
Third 6-in-1 vaccine DTap/IPV/Hib/HepB Vaccination 3rd dose
Second MenB Second meningitis B vaccination
Please give a date when the child received their one year vaccinations One year imms
Second Pneumococcal vaccine Pneumococcal (PCV) vaccine, 2nd dose
First Measles, Mumps, Rubella Vaccine Pneumococcal (PCV) vaccine, 2nd dose
Booster MenB Booster meningitis B vaccination
Hib/MenC vaccine Haemophilus influenzae type b (Hib) and meningitis C.
Please give a date when the child received their pre school vaccines Pre school imms
4-in-1 pre-school booster diphtheria, tetanus,whooping cough, polio
Second Measles, Mumps, Rubella Vaccine Second Measles, Mumps, Rubella Vaccine 2nd dose
Online services and text messaging Would you like to register for online services?(Required) You can book/cancel appointments, order prescriptions and see your read coded record and results online
Do you consent to receiving SMS messages?(Required) Do you consent to receiving Email messages?(Required) NHS patient information sharing - my choices This section of the form covers the Summary Care Record and the Enhanced Data Sharing Model 'SystmOne'. If you would like to know more about these things, please see the following links.
NHS Health Records Please complete and/or tick the boxes below to detail your personal decisions regarding the 2 aspects of NHS patient data sharing. It is very important you sign this form to say that you understand and accept the risks to your personal health care if you do decide to opt out of SCR or EDSM. You will need to do this when you next visit the surgery.
1. SCR - NHS SUMMARY CARE RECORD(Required) Is a summary of a patient's sensitivities/allergies/current medication, which is uploaded to the national Spine. It can be accessed by any legitimate Clinician and is beneficial when a patient is seen at a hospital /Out of Hours/temporary resident at a GP practice. It is advisable to stay registered for this service.
EDSM – ENHANCED DATA SHARING MODEL "SystmOne" Sharing Out – Do you consent to the sharing of data recorded by your GP practice with other NHS organisations that may care for you?(Required) Sharing In – Do you consent to your GP Practice viewing data that is recorded at other NHS organisations and care services that may care for you?(Required) Signature You will be asked to sign this form when you visit the practice and provide ID and proof of address.
If you were born outside of the UK, bring your Passport and Visa with you.
Today's date Consent(Required) By submitting your details you are consenting to providing this information for improving our services to you. The data you supply on this form will be securely stored on our website, which is hosted by a third party. We will retain this information on the website for no longer than 7 calendar days. Your contact details will not be sold or shared with a third party. I understand I can revoke this consent at anytime by contacting the practice. Our privacy policy can be viewed on this website.
I agree to the privacy policy.
