New Patient Registration

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.

You are required to be present in person to sign your registration form and provide proof of your address.

Sending this form does NOT guarantee or even imply that you will be accepted onto the practice register.

We have just published a new policy on how we manage GP prescribing requests and shared care agreements with private providers. to view this policy, click here.


Patient's Details

Your Name
(if applicable)
Date of Birth
(If known)
Home Address
(Please also provide flat number or room number where appropriate)
Email Address

Further Details

(If none enter “None”)
Are you a student?

Contacting You



We will from time to time have to contact patients via SMS text message. this is extremely helpful particularly in the current state of pandemic.

Do you agree that you may be contacted from time to time, via email and/or SMS, with practice news, advice about my health and/or appointment reminders?

Previous Medical Records

Please help us trace your previous medical records by providing the following information.
Have you registered with the NHS before?
Are you from abroad?
Are you returning from the Armed Forces?

Dispensing Of Medicines And Appliances

If you need a doctor to dispense medicines and appliances
(Not all doctors are authorised to dispense medicines)

Organ & Blood Donation

Would you like to register as an organ donor?
Are you/Would you like to register as a blood donor?

Supplementary Questions

Are you ordinarily resident in the UK?
Patient Declaration Conf
(A parent/guardian should complete the form on behalf of a child under 16)
Are you completing this form on behalf of a child under 16?

Non-UK European Health Insurance Card (EHIC), Provisional Replacement Certificate (PRC) Details

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 member state. Do not complete this section if you have an EHIC issued by the UK
Do you have a non-UK EHIC or PRC?

S1 Form

Do you have an S1 form? If yes, please give your S1 form to the practice staff.
(e.g. 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)

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.

Proof of Identity and Address Provided

We require proof of identity and address – please email a copy of your identity as well as proof of address to andover.medical-centre@nhs.net with “New registration ID” as the subject header. If you do not provide us with proof of ID and address we may be unable to proceed with your registration.
Proof of Identity
Drop files here or
Max. file size: 1 GB, Max. files: 10.
    Proof of Address, Proof of Identity etc

    Carers

    Do you have a carer?
    Are you a carer?

    Next of Kin Information

    Please provide us with information of your Next of Kin – Somebody we can contact in a state of emergency.
    Do you have any "Next of Kin" you would like us to contact in the case of an emergency?

    Online access to your medical records

    We are offering patients access to their online records. You can view test results, history and request repeat medication without hassle.
    Would you like online access?

    Living Will

    Do you hold a Living Will?

    Lifestyle

    Do you smoke?
    Do you take regular exercise?
    (In CM please)
    (In LBS pelase)

    Alcohol

    MEN: How often do you have EIGHT or more drinks on one occasion? WOMEN: How often do you have SIX or more drinks on one occasion?
    How often during the last year have you failed to do what was normally expected of you because of drinking?
    How often during the last year have you failed to do what was normally expected of you because of drinking?
    In the last year has a relative or friend, or a doctor or other health worker been concerned about your drinking or suggested you cut down?

    Family History

    Please state your relationship to the individual and in the case of cancer, the type of cancer.

    Medical Information

    Please complete this section as accurately as possible.
    Are you registered disabled?
    Are you currently taking any medication?
    Are you allergic to any medicines?
    If none, please state “None”
    Have you ever suffered from?
    (tick as appropriate)
    Have you ever refused treatment/screening of any kind?
    Have you ever suffered from any of the below?
    (Please tick as appropriate)
    Do you have any other mental health conditions/issues?

    Women's Health

    Were you born with female sexual organs?

    Patient Participation Group

    We would like to invite you to join our Patient Participation Group! Do you want to improve health and health services in your local community? Do you want to have the opportunity to have a voice and get involved in the way your health service is run? Do you want to help shape and improve services and even get involved in shaping and delivering new and exciting services?
    Would you like to become a member of Patient Participation Group?

    Complete Registration

    Please note – if there are any queries we will contact you in order to obtain more information. your registration may not be processed until this information is obtained. Also, you may not be able to see a GP until you have had a new patient health check with our nursing team.
    If you are registering a child under 5
    If you need your doctor to dispense medicines and appliances
    Signature
    (Full Name)