Patient's details Title(Required) Date of birth(Required) Do you know the NHS number of the person you are registering?(Required) You can find your NHS number by visiting the NHS website.
For children, you can also find their NHS number in their Red Book.
Sex(Required) Home address in the UK(Required)
Please help us trace your previous medical records by providing the following information ALL previous addresses in UK(Required) Please enter N/A if not applicable
Your first UK address where registered with a GP(Required) Please enter N/A if not applicable
Blood and organ donation
Do you have a non-UK EHIC or PRC?(Required) If you select yes please complete the additional details from your EHIC card that will appear below.
Date of birth(Required) Expiry date(Required) PRC validity period (a) From:(Required) PRC validity period (b) To:(Required) S1 form Please tick this box if you have an S1 (eg 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). Please give your S1 form to practice staff.
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.
More about who you are registering Who is being registered?(Required) Please choose the correct age band so we can show you the correct questions below.
Email(Required) Are you retired?(Required) Are you homeless?(Required) If you are homeless, may we use the address you registered with for confidential post?(Required)
Were you ever registered with an Armed Forces GP 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(Required) Address before enlisting(Required) Please enter N/A if not applicable
Enlistment date Discharge date (if applicable) Footnote: 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 and service charities services.
Next of kin Do they have any formal power of attorney for medical care? (if so, please attach the certificates below)(Required) Note, we will only contact this person in case of emergencies, and we will never share confidential information without your consent
More about a child or newborn Their current home address(Required)
Does the child attend a place of education?(Required) Place of education(Required) Name and address of school/nursery attended(Required)
Interpreter Do you require an interpreter?(Required) We offer double appointments for patients who need a language interpreter or BSL. Please ask at reception when booking an appointment.
Lifestyle questions Are you a smoker?(Required) If yes – we offer smoking cessation services at the practice. Please tick if you would like more information about this.
Please send me smoking cessation services information(Required) How often do you physically exercise?(Required) How often do you have a drink containing alcohol?(Required) How many units of alcohol do you drink on a typical day when you are drinking?(Required) 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?(Required)
Alcohol consumption – Part Two How often during the last year have you found that you were not able to stop drinking once you had started?(Required) How often during the last year have you failed to do what was normally expected from you because of your drinking?(Required) How often during the last year have you needed an alcoholic drink in the morning to get yourself going after a heavy drinking session?(Required) How often during the last year have you had a feeling of guilt or remorse after drinking?(Required) How often during the last year have you been unable to remember what happened the night before because you had been drinking?(Required) Have you or somebody else been injured as a result of your drinking?(Required) Has a relative or friend, doctor or other health worker been concerned about your drinking or suggested that you cut down?(Required)
Further health questions Do you have any allergies? YES (please specify)(Required) Allergy details(Required)
Are you currently receiving care elsewhere? Please provide further information(Required)
Please list below your current repeat medication(Required)
Do you currently have or had any of the following?(Required)
Family history Are you adopted?(Required) Does anyone in your family have or previously had any of the following(Required)
Females only Please let us know the date of your last cervical screening (smear) test (if you are over 25 years old)
Have you had any children?(Required) Please give the dates of birth of your children(Required)
Have you had a hysterectomy?(Required) Do you have a coil or implant?(Required) Are you a carer or a young carer?(Required) Do you have a carer yourself?(Required) Do you have a social worker?(Required) If yes, please provide the name and contact details(Required)
Are you a looked after child?(Required) Who are you living with?(Required) If yes, please provide the name and contact details(Required)
Gender identity At birth were you described as Have you gone through any part of a process (including thoughts or actions) to change from the sex you were described as at birth to the gender you identify with, or do you intend to? (This could include changing your name, wearing different clothes taking hormones or having any gender reassignment surgery). Continuing to think about these examples, which of the following options best applies to you? Please tick one option Which of the following describes how you think of yourself? (tick all that apply) I think of myself in another way as described here
Sexual orientation
Ethnicity Do you have a learning disability?(Required) Do you need information communicated to you in a specific format?(Required) Do you need support when attending the surgery?(Required) If yes, please describe any special help you require: (e.g. unable to manage stairs, easy-read information, sight/hearing assistance)
Please tick here if you would like to be added to our PPG mailing list, to receive news and invitations to PPG meetings Have you / the child received all the usual UK childhood vaccinations?(Required) You / the child had all the childhood vaccinations in the UK(Required) Please let us know which childhood vaccinations they have received(Required) Please give a date when the child received their 8 week vaccinations(Required) Please give a date when the child received their 12 week vaccinations(Required) Please give a date when the child received their 16 week vaccinations(Required) Please give a date when the child received their 1 year vaccinations(Required) Please give a date when the child received their 3 year 4 month vaccinations(Required) Do you consent to receiving SMS messages?(Required) Do you consent to receiving email messages?(Required)
Students only Students are at risk of certain infections including mumps, meningitis and sexually transmitted infections, as well as
mental health issues including stress, anxiety and depression. Please see www.nhs.uk/Livewell/Studenthealth
I am less than 24 years old and have had two doses of the MMR Vaccination I am less than 25 years old and have had a Meningitis C Vaccination Please complete and/or tick the boxes below to detail your personal decisions regarding the 2 aspects of NHS patient data sharing. It is very important you sign this form to say that you understand and accept the risks to your personal health care if you do decide to opt out of SCR or EDSM. You will need to do this when you next visit the surgery.
1. SCR - NHS SUMMARY CARE RECORD(Required) Is a summary of a patient's sensitivities/allergies/current medication, which is uploaded to the national Spine. It can be accessed by any legitimate Clinician and is beneficial when a patient is seen at a hospital /Out of Hours/temporary resident at a GP practice. It is advisable to stay registered for this service.
EDSM – ENHANCED DATA SHARING MODEL "SystmOne" Sharing Out – Do you consent to the sharing of data recorded by your GP practice with other NHS organisations that may care for you?(Required) Sharing In – Do you consent to your GP Practice viewing data that is recorded at other NHS organisations and care services that may care for you?(Required) Today's date Consent(Required) By submitting your details you are consenting to providing this information for improving our services to you. The data you supply on this form will be securely stored on our website, which is hosted by a third party. We will retain this information on the website for no longer than 7 calendar days. Your contact details will not be sold or shared with a third party. I understand I can revoke this consent at anytime by contacting the practice. Our privacy policy can be viewed on this website.
I agree to the privacy policy.
