New Patient Registration Form

This form is for patients aged 16 and over, who wish to register with us.

You must complete the form in one sitting, so please set aside at least 15 minutes to do this.

This is an "intelligent" form, which may add or remove questions based on your answers, for example if we need more details, or if a question is not applicable to you.

Please read all the information carefully, as you will be asked to decide on your consent to a number of different questions.

If you need help navigating the form, or you would prefer to complete a paper copy, please call the Practice.

Page {{ paginatorProps.current }} of {{ paginatorProps.total }} ({{ paginatorProps.percentage }}% completed)
Your personal information
Please provide a UK Telephone number (landline or mobile) so we can book Telephone Consultations with the Doctors or Nurses.
Please help us trace your previous medical records by providing the following information
If you are from abroad
If you have ever been registered with an Armed Forces GP
Ethnicity
Summary Care Record
If you require any more information, please visit http://digital.nhs.uk/scr/patients or phone NHS Digital on 0300 303 5678 or speak to your GP practice.
Sharing your health record
Note: You can request individual entries in your record to be marked as “Private”. These are not shared with the rest of your record even if you choose to share OUT.
Please contact the Patient Experience Team on 0800 273 2535 or capccg.pet@nhs.net if you have any queries.
Your medical history
If you smoke, we would advise you to stop and welcome you to make an appointment with our team for smoking cessation advice, or visit www.nhs.uk/smokefree
If you have come from abroad please bring in a copy of your medical and vaccination record.
Alcohol Questionnaire
If your total score for questions 1 to 10 is 8+, we would like to invite you to make an appointment with our practice nurse to discuss this further. You can also visit: www.units.nhs.uk/
Electronic Prescription Service - Patient Nomination Request
Next of kin
Signature
Proof of identity and proof of address

Privacy Consent

This form collects personal and medical information about you. We use this information to allow the practice team to contact you. Please read our Privacy Policy to discover how we protect and manage your submitted data.

 
Processing

Page you are trying to access does not exist.