New Patient Registration (Over 16)

If you are new to the area and wish to register with the GP surgery, please complete the form below – each person registering will need to complete a form.

Non-urgent advice: Please note

There is a different form for children aged under 16 – New Patient Registration Form (Child: Under 16 years).

Personal Details

Title
Date of Birth
Gender
*Please include borough if born in London
Address
We will use your mobile number to send appointment reminders and health promotion details.
Email
How would you prefer us to contact you?

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

Your previous address in the UK
Address of previous doctor

If you are from abroad

Your first UK address where registered with a GP
If previously resident in UK, date of leaving
Date you first came to live in the UK
If this is your first GP registration in the UK, please provide us the name of the country and date of arrival.
TB test Offered
TB test accepted

Armed Forces

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:
Enlistment date
Discharge date (if applicable)
Please note that these questions are optional, and your answers will not affect your entitlement to register or receive services from the NHS but may improve access to some NHS priority or service charities services.

NHS Charges Regulations 2015 Self Declaration

I am a British Resident and entitled to full NHS Care
I have paid the Immigration Health Surcharge (IHS)
I hold a non-UK issued European Health Insurance Card (EHIC) (Complete details on reverse of GMS1 form)
I hold a S1 form (entitlement to health care in another EEA country for a limited duration)

Demographics

Marital Status
What is your main religion?

Do you have access to secure housing?
What is your current immigration status?

Carers

Do you have caring responsibilities?
Do you have a carer?

Next of Kin

Your choice should be someone you feel close to. It does not have to be a blood relative or spouse. Before listing them on any medical documents, you should ask their permission and explain the role.
Do you give us permission to discuss your medical records with them?

Communication and Access Needs

Do you speak English?
Do you read English?
Are you a British Sign Language user?
Do you need an interpreter?

Disability

Do you have an impairment, health condition or learning difference that has a substantial or long-term (over a year) impact on your ability to carry out day-to-day activities? (Tick all that apply)
Are you an ‘Assistance Dog’ User?
Are you housebound?

Health Information

(in centimetres)
(in kilograms)
Smoking Status

How many of the below do you smoke per day?

Alcohol Consumption

This is one unit of alcohol:

  • Half pint of regular Beer/Lager/Cider
  • 1 small glass of wine
  • 1 single measure of spirits
  • 1 single measure of aperitifs
  • 1 small glass of sherry

Each of these is more than one unit:

  • Pint of regular Beer/Lager/Cider (2 Units)
  • Pint of Premium Beer/Lager/Cider (3 Units)
  • Alcopop or can/bottle of regular Lager (1.5 Units)
  • Can of Premium Lager/Strong Beer (2 Units)
  • Can of super strength lager (4 Units)
  • Glass of wine (2 Units)
  • Bottle of wine (9 Units)
How often do you have a drink containing alcohol?
How many units of alcohol do you drink on a typical day when you are drinking?
How often have you had 6 or more units if female, or 8 or more if male, on a single occasion in the last year?

Medical History

Have you or anyone in your family (brother, sister, parents, grandparents, aunt, uncle) had any of the following?

Women Only

What is the date and result of your last Smear test?

Was this at:

Current Medication

Are you able to administer your own medicines?

Allergies

Do you have any allergies?

Immunisation History

Please include dates

Further Information

Do you have a ‘Living Will’ or ‘Advanced Directive’?
An advance decision (sometimes known as an advance decision to refuse treatment, an ADRT, or a living will) is a decision you can make now to refuse a specific type of treatment at some time in the future.
Have you nominated someone who has Power of Attorney or been assigned a Personal Welfare Deputy?

Online Services

For anyone aged 16 and over, we offer online services for appointment booking and repeat prescription ordering. This is the quickest and easiest way to order your medication. Once registered, you will also be able to view your summary record, detailing current medication, allergies and vaccinations.

You will soon receive an email from the practice with your log in details.

These are confidential: It is your responsibility to ensure they can be received securely by email.

Summary Care Record

This record will contain summary information about any medicines you are taking, allergies you suffer from and any bad reactions to medicines you have had to ensure those caring for you have enough information to treat you safely.

Your Summary Care Record will be available to authorised healthcare staff providing you with care anywhere in England, but they will ask your permission before they look at it. This means that if you have an accident or become ill away from home, healthcare staff treating you will have immediate access to important information about your health.

Do you consent to having a Summary Care Record?
Medical Record Sharing allows your complete GP medical record to be made available to authorised healthcare professionals involved in your care. You will always be asked your permission before anybody looks at your shared medical record.
Do you want to share your GP record?

Your Medical Information – Sharing Your Data

Under the General Data Protection Regulations (GDPR), we have a responsibility to keep your medical records confidential. We need your consent to share this with other authorised health professionals involved in your care or in planning your care. You can find more information on the website at www.nhs.uk/your-nhs-data-matters.

Please see the privacy notice on our website for more information on how your data is held and used by the practice.

The NHS wants to make sure you and your family has the best care now and in the future. Your health and adult social care information supports your individual care. It also helps us to research, plan and improve health and care services in England.

There are very strict rules on how this data can and cannot be used, and you have clear data rights. We are committed to keeping patient information safe and will always be clear on how it is used.

You can choose whether or not your confidential patient information is used for research and planning.

If you do not wish your information to be used in this way please opt-out by visiting NHS: Your Data Matters or by calling 0300 303 5678. The practice is unable to record this for you.

NHS Organ Donor registration

For more information on organ donation please visit: www.organdonation.nhs.uk

NHS Blood Donor registration

If you would like to join the NHS Blood Donor Register as someone who may be contacted and would be prepared to donate blood, please visit their website on: www.blood.co.uk or call direct on 03001232323

Signature

Declaration
Your Full Name
Date