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
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
SECTION E: Carers
SECTION F: Next of kin & emergency contact
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
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
SECTION M: Parent declaration