New Patient Registration

We are currently open to new patients.

Please fill out this form and then attach a copy of your ID at the end or come into the practice with your ID. If you have any issues or queries, please contact the practice.

To register a new patient you will need to live within our practice boundary; please contact the practice for further information.

New Patient Registration

Background Details

Contact Details

Title *
(if applicable)
Please use this date format: DD/MM/YYYY
Sex *
If you have had a previous GP then you will find this on letters/prescriptions or at www.nhs.uk/find-nhs-number
Which of the following best describes how you think of yourself?
Is your gender the same as the sex you were assigned at birth?
Any responses we send will go to this email address.

It is your responsibility to keep us updated with any changes to your telephone number, email and postal address.

We may contact you by SMS or email with appointment details, test results, health campaigns or Patient Participation Group details.

Do you consent to being contacted by SMS with appointment details, test results, health campaigns or Patient Participation Group details?
Do you consent to being contacted by email with appointment details, test results, health campaigns or Patient Participation Group details?

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?

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

Other Details

Please include postcode.

Please specify the ethnic group you consider you belong to:
Please specify your religion:
Please specify your housing status:
Please specify your employment status:

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:
Please include postcode
Please use this date format: DD/MM/YYYY
Please use this date format: DD/MM/YYYY

Communication Needs

Do you need an interpreter?
Do you speak English?
Do you read English?
Do you have any communication needs?
Please specify your communication needs:
Do you have a Learning Disability?

please request a Learning Disability Screening Tool form

Carer Details

Are you a carer for someone?
Do you have a carer?

Only add carer’s details if they give their consent to have these details stored on your medical record

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

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/visitingengland.

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.

Please bring the details of your EHIC or PRC with you to the surgery.

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.