New Patient Registration Form

Fields marked are compulsory. You should only send this form if you are sure that you are eligible to join this practice. Sending this form will not automatically register you with the surgery. Your details will be held at the surgery for a limited period of time. Sending this form does not guarantee or even imply that you will be accepted onto the practice register.

Last Updated: 08/06/2022

SECTION A: Patient's Details (please only provide details here for the patient, translator/carer details can be provided further on in the form)
























SECTION B: Data sharing

It is possible to view and share information on your medical record with other organisations providing NHS care to you such as Hospitals and Community Care Teams. Data will only be shared and viewed with your consent.


SECTION C: Are you an Armed Forces veteran or have you ever been registered with an Armed Forces GP?








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

Please enter N/A if you have remained at the same address.





SECTION E: Carers

Carers are people who provide unpaid care and support to family members and friends who have a disability, mental illness, chronic condition, terminal illness, an alcohol or other drug issue or who are frail aged.







SECTION F: Next of kin & emergency contact

Your Next of Kin is the person who will be contacted in case of an emergency. In the UK, a next of kin is usually a relative (or relatives) who you have the closest relationship with but it could also be a partner or a close friend. Please ensure UK contact details are provided. If your next of kin and emergency contact is not the same person please provide details below.








SECTION G: Health information



























SECTION H: If you were not born in the UK please complete the below. Failure to provide this information will result in your registration not being processed. If you were born in the UK please skip to section D.






SECTION I: Residential or Nursing Care Homes

Please forward to us your recent discharge summary or summary if it was a community health referral. Please also provide your medication list.


SECTION J: Summary Care Record

Summary Care Records (SCR) are an electronic record of important patient information, created from GP medical records.

Please visit https://digital.nhs.uk/services/summary-care-records-scr for information on what is stored and how it may be used.




SECTION K: Female health





SECTION L: PATIENT DECLARATION for all patients who are not ordinarily resident in the UK

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. 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. To ensure accuracy we will contact you to provide ID Documentation showing the patients full names and date of birth as well as proof of address, if you are unable to provide this documentation your registration may be delayed.




SECTION M: Parent declaration

Please complete if the patient is under the age of sixteen.