Register as a Patient

Please use the postcode checker above to ensure you are living in our area before filling in the form below.

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Patient's Details
Title*
Surname*
Previous Surname
First Name*
Date of Birth*
Gender*
NHS Number*
If you are unsure, you can contact your current G.P or Dental Practice, who will be able to provide this for you.
Town and Country of Birth*
Home Address*
Post Code*
Email Address
Would you like to join our Virtual Patient Participation Group?
- Yes
- No
We invite all of our patients to join our Virtual PPG. From time to time we will email you with a question or a survey which we would very much like your opinion on. If at anytime you no longer want to be part of the Virtual PPG, simply contact your local surgery and you will be removed from our contacts list. The information you supply us will be used lawfully, in accordance with the Data Protection Act .The Data Protection Act gives you the right to know what information is held about you, and sets out rules to make sure that this information is handled properly.
Primary Telephone Number*
Secondary Telephone Number
Other Details
Ethnicity
Religion
Allergies
Do you have any allergies?*
If you answered yes to the question above, please list your allergies in the space below

Please help us trace your previous medical records by providing the following information
Your previous address in UK (including post code)
Name of previous doctor while at that address
Address of previous doctor
If you are from abroad
Your first UK address where registered with a G.P
If previously resident in UK, date of leaving
Date you first came to live in the UK
If you are returning from the Armed Forces
Address before enlisting
Service or Personnel number
Enlistment date

Accessible Information Standard
Please use this page to let us know if you or someone you care for has information and/or communication needs relating to a disability, impairment or sensory loss
Does the person being registered have communication needs?
Does the person being registered need a format other than standard print
Does the person being registered have any special communication needs?
Preferred method to be contacted
How do you prefer to contact us
Please use the space below to explain any communication/information support we could provide for you.

Current Medical History
Please select if you suffer from or have had any of the following illnesses
Please list any operations that you have had
Please list any medication and dosage you are currently taking
Your Weight
Your Height
What type of excercise do you take and how often?
Please list any allergies you have
Do you smoke?
If you answered yes to the question above, how many cigarettes do you smoke a day?
How often do you have a drink that contains alcohol?
How many standard alcoholic drinks do you have on a typical day when you are drinking?
How often do you have 6 or more standard drinks on one occasion?
Immunisations
Please list any vaccinations you have received and dates given. Patients 15 years and under - complete details are required. If in doubt please bring in your red book.
For Women Only
How many pregnancies have you had?
Date of last Cervical Smear
Carer information
Is the person being registered a carer?
Is the person being registered being cared for?
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- First Choice
- Second Choice
- Third Choice
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- First Choice
- Second Choice
- Third Choice

Patient's Details