New patient registration

Patient’s Details

Please specify:

Surname:

Previous Surnames:

First Name(s)

Date of Birth:

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

Gender

Male

Female

Indeterminate

NHS Number:

Home Address:

Postcode:

Town and Country of birth:

Home Phone Number:

Mobile Phone Number:

Work Phone Number:

Email Address:

Can we contact you by text?

Yes

No

Can we contact you by email?

Yes

No

Would you like to register for our online services?

Yes

No

Terms and Conditions

I understand that It is my responsibility to keep my account secure by keeping my details confidential I understand that I can terminate my account at any time by contacting the surgery, or change my log in details by re-registering and that this form will be kept on my electronic records I understand that my registration will be revoked if I constantly miss or cancel appointments.

I accept the terms and conditions stated above

For Practice Use Only

For use if patient wishes to register for online services

Patient NHS Number

Practice computer ID number

Identity verified by (initials)

Date

Method

Vouching

Vouching with information in record

Photo ID and proof of residence

Authorised by

Date

Date account created

Date passphrase sent

Notes / explanation

Ethnicity

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.

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

Tell us whether you accept cookies

Patient’s Details

Terms and Conditions

For Practice Use Only

Ethnicity

Emergency Contact

Allergies

Previous Details

If you are from abroad

If you are returning from abroad

Carers