New Patient Registration

How to Register

You can register with the practice either online or in person. You will need to complete both the Purple New Patient GMS1 form and the Adult Registration Form. This can be done by either completing this online form or by downloading and completing the documents below and then bringing them into the practice.

• Adult Registration Form
• Purple New Patient GMS1
• New Patient Registration Pack

Please Note: Once you have completed the forms either online or printed them off you must come into the practice with 2 forms of identification to complete your registration. You can view the list of acceptable identification documents in the New Patient Registration Pack.

New Patient Registration

If you are human, leave this field blank.

Practice Catchment Area

Have you checked that you live within our practice catchment area? *

Yes

No

Please check that you live within our Practice Catchment Area.

If you do not live within our practice catchment area, please do not register with this practice: Practice Catchment Area.

Patient's Details

Title *

Mr

Mrs

Miss

Ms

Other

Please specify:

Surname: *

Previous Surnames:

First Name(s) *

Date of Birth: *

Please use this date format: DD/MM/YYYY.

NHS Number:

Which of the following best describes how you think of yourself? *

Male

Female

Non-binary

Prefer to self-describe

Is your gender identity the same as the sex you were assigned at birth? *

Yes

No

We are asking for this information to match your GP record.

Home Address: *

Postcode: *

Town and Country of birth: *

Home Phone Number:

Mobile Phone Number:

Work Phone Number:

Email Address: *

Do you consent to receiving text messages from the practice?

Yes

No

This may include general practice information i.e. flu clinic dates, health promotion etc.

Do you consent to receiving emails from the practice?

Yes

No

This may include general practice information i.e. Newsletters, health promotion, notice of flu clinics etc.

Marital Status: *

Please list all the residents of your home and give ages of children (if applicable): *

Ethnicity

Please specify the ethnic group you consider you belong to:

White British

White Irish

Other White

Black Caribbean

Black African

Other Black

Black Caribbean and White

Black African and White

Other Mixed

Indian

Pakistani

Bangladeshi

Other Asian

I do not wish to state

Other ethnic group

Please state:

Do you speak English?

Yes

No

Do you read English?

Yes

No

First Language:

Emergency Contact

Full Name:

Relationship to you:

Phone Number:

Are they your Next of Kin?

Yes

No

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

Yes

No

Allergies

Do you have any allergies?

Yes

No

Please specify what you are allergic to, what happens and when you had your first reaction:

Previous Details

Previous address in UK:

Please include postcode.

Name and address of previous GP:

If you are from abroad

Registering for the first time in the UK

Date you came to live in the UK:

Please use this date format: DD/MM/YYYY.

If you are returning from abroad

Previously been a resident in the UK

Date you left the UK:

Please use this date format: DD/MM/YYYY.

Date you returned to the UK:

Please use this date format: DD/MM/YYYY.

Veterans

Are you an Armed Forces Veteran?

Yes

No

Which Service?

When did you leave?

Carers

Do you have a carer?

Yes

No

Are you a carer for someone?

Yes

No

Name of carer:

Phone Number:

Address:

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

Yes

No

Don't forget to print off the Purple GMS1 form and bring this into the surgery with your ID.

Name of person cared for:

Address of person cared for:

Phone number of person cared for:

Please check that the person is happy to be contacted in an emergency should you become unwell whilst on surgery premises