Registration Form

Which sections should be completed?

Part A – all sections that apply.

Part B – this section is optional, but will help the GP provide the best care.

Part C – only complete these sections if you do not normally live in the UK.

You may be contacted by the GP surgery if you do not complete all the relevant sections

PART A

Try to provide as much information as possible. If a question does not apply to you or the person you are registering write ‘Not applicable’ or ‘N/A’

Section 1 – Who is registering?

Are you registering..

Yourself

Someone else

Only provide your details if you are registering someone else.

Your name

Your relationship to patient

Your contact phone number

Section 2 – Details of patient registering

Title

First name

Last name

Middle name (if you have one) Optional

Previous last name Optional

Date of Birth

What is your sex as recorded on your NHS record?

Female

Male

Intersex

Not specified or known

NHS Number (if known) Optional

Village, town or city of birth

Country of birth

If you have no fixed address, please tick yes

Yes Optional

N/A Optional

Current Address

Street Address Address Line 2 City Post code

The practice catchment area is E17, any registrations of patients residing outside of this postcode will not be registered

What postcode did you give to the last GP surgery you registered with? Optional

Name and address of UK GP surgery you registered with

Street Address Address Line 2 City Post code

Have you ever lived somewhere else in the UK?

Yes

Last address in the UK

Street Address Address Line 2 City Postcode

The NHS and your GP surgery can use these details to call, text or email you about health care services. All phone numbers must be registered in the UK

Home phone number Optional

Mobile phone number

Enter Email Optional Confirm Email Optional

Name of emergency contact

Phone number of emergency contact

Their relationship to you

Name of next of kin

Phone number of next of kin

Their relationship to you

Section 3 – Patients under 18 years

Is this registration for a child under the age of 12 month?

Yes

Where were they born?

England

Northern Island

Isle of Man

Wales

Scotland

Outside of the UK

Where was the mother living when the baby was born?

Street Address Optional Address Line 2 Optional City Optional Postcode Optional

Is this registration for a patient under the age of 18?

Yes

Do you attend any of the following?

School

Nursery

Home school

None of these

School / Nursery address

Street Address Optional Address Line 2 Optional City Optional Postcode Optional

Are any of these involved in your care?

Hospital specialist

Health worker

Social worker

None of these

Have you had all your routine vaccinations?

Yes

Don’t know

Did you get your routine vaccinations in the UK?

Yes

Don’t know

Section 4 – Additional information

What is your ethnic group?

White

Mixed or multiple ethnic groups

Asian or Asian British

Black/African/Caribbean/British

Other ethnic group

Prefer not to say

Ethnicity

English, Welsh, Scottish, Northern Irish or British

Irish

Gypsy or Irish Traveller

Any other White background

Ethnicity

White and Black Caribbean

White and Black African

White and Asian

Any other Mixed or Multiple ethnic background

Ethnicity

Indian

Pakistani

Bangladeshi

Chinese

Any other Asian background

Ethnicity

African

Caribbean

Any other Black, African or Caribbean background

Ethnicity

Arab

Any other ethnic group

Have you registered with a UK GP before?

Yes

If you have moved to the UK, what date did you arrive?

Have you ever served in the UK Armed Forces or were you ever registered with a Ministry of Defence GP in the UK or overseas?

Yes

Prefer not to say

If you were given a FMED133A form (sometimes called an FMED1 form) when you left the UK Armed forces, you should give this to your GP surgery.

Do you need an interpreter for your appointments?

Yes

What language?

British Sign Language (BSL)

Yes Optional

Are you a carer?

Yes

What is your relationship to the person you are caring for?

What type of carer are you?

Young carer, under 18

Unpaid, but may get benefits

Paid as a job

Foster carer

Do you have a carer?

Yes

What is your relationship to your carer?

What type of carer are you?

Young carer, under 18

Unpaid, but may get benefits

Paid as a job

Foster carer

Carer’s contact telephone number

What pharmacy do you want your prescriptions sent to?

Pharmacy address

Street Address Optional Address Line 2 Optional City Optional Postcode Optional

You can sometimes collect your prescription items from your GP surgery instead of having to go to a pharmacy. Your surgery may discuss this with you

Do you live more than 1 mile from your nearest pharmacy?

Yes

Would you have serious difficulty getting medicines or appliances from your nearest pharmacy?

Yes

Your GP surgery needs permission to share important information from your GP record. This is called a Summary Care Record (SCR). Your SCR can only be shared with health and care staff across England who are providing you with direct care. It gives them access to vital information from your GP record

Do you want important information from your GP record to be available to other health and care professionals?

Yes, share a Summary Care Record with additional information: Includes details of your medicines, allergies, adverse reactions and additional information, which includes details of any significant illnesses and health problems, operations and vaccinations

Yes, share a Summary Care Record without additional information: Includes details of your medicines, allergies and adverse reactions only

No, do not share a Summary Care Record: Details of your medicines, allergies, adverse reactions and any additional information will not be shared with anyone involved in your direct care

PART B

You do not have to complete this section. But any information you do give will help the GP give you the best care.

Section 5 – Patient health

Have you ever had any of these conditions?

What best describes you?

I smoke Optional

I used to smoke Optional

I have never smoked Optional

Prefer not to say Optional

On average, how many cigarettes do you smoke a day?

What date did you stop smoking?

How often do you drink alcohol?

Never Optional

Monthly or less Optional

2 to 4 times a month Optional

2 to 3 times a week Optional

4 or more times a week Optional

Prefer not to say Optional

How many units of alcohol do you drink on a typical day when you are drinking? Optional

1 pint of 4% beer is 2.5 units. a small 125ml glass of wine is 1.5 units and a 25ml shot of spirits is 1 unit.

How often have you had six or more units of alcohol on a single occasion in the last year?

Never Optional

Less than monthly Optional

Monthly Optional

Weekly Optional

Daily or almost daily Optional

Prefer not to say Optional

What is your weight?

Kilograms Optional

Stone Optional

Pounds Optional

What is your height?

Centimeters Optional

Foot Optional

Inches Optional

Allergies Optional

Mental health conditions Optional

Disabilities Optional

Other medical conditions Optional

Give details of any medication you are taking Optional

Are any of these repeat prescriptions?

Yes Optional

No Optional

Do you or your carer need to be communicated in an accessible format?

Yes Optional

No Optional

For example, braille, audio, large format or EasyRead

Tell us what you need Optional

Do you or your carer need any reasonable adjustments to make your visit to the GP surgery accessible?

Yes Optional

No Optional

For example, an audible or visual alert in the waiting room, access to a hearing loop or the support of a note taker

Tell us what you need Optional

PART C

Section 6 – Patients from abroad

Complete this section if you are:

visiting the UK and do not normally live here.

currently living in the UK, but do not think of it as your permanent country of residence. For example, you are studying here or have come to the UK as part of your job.

a permanent resident in the UK and receive a pension or benefit from a European country

Information on eligibility to free care outside the GP practice

Anyone can register with a GP practice and receive free medical care from that practice. However, should you be referred for treatment outside the practice or need unplanned care, for example at a hospital, charges may apply if you are a visitor or temporary resident.

Some groups of visitors or temporary residents are eligible to receive this care free of charge. Documentation may be required to demonstrate eligibility.

Examples of those eligible include:

refugees, asylum seekers, those receiving certain forms of state support

suspected or confirmed victims of modern slavery and human trafficking

temporary residents with a valid visa of over 6 months. You may have paid the immigration health surcharge with your visa application. Note that assisted conception services remain chargeable to this group

visitors from the EEA will need to provide their EHIC (European Health Insurance Card), which covers immediately necessary unplanned treatment, or a S2 form which covers planned treatment.

Additionally, some services are free of charge to all visitors, including diagnosis and treatment for infectious diseases and sexually transmitted infections.

Immediate necessary care, maternity care and other urgent care that cannot wait until a chargeable visitor’s departure from the UK will not be withheld or delayed due to charges. But non-urgent treatment will not be given until full payment is received.

More information can be found in the patient leaflet available from the GP practice.

Select the statement that applies to you

I understand I may have to pay for NHS treatment outside of the GP practice Optional

I do not have to pay for NHS treatment outside of the GP practice and have documents to prove this Optional

I do not know if I have to pay for treatment Optional

Giving us this information means that if you need NHS care outside the GP practice and you are entitled to that care without charge, it will be easier for you to demonstrate this entitlement.

We’ll use the information to establish your chargeable status in order to recover NHS costs from countries responsible for your healthcare where applicable. This will not impact your entitlement to register with the GP practice or to receive free GP services.

Tick one of the following

I have an S1 form issued by an EU or EEA member state Optional

I am entitled to an EHIC card, but I do not have one Optional

I have an EHIC card issued by an EU or EEA member state Optional

I am in receipt of a European pension or benefit Optional

I am in the UK as part of my employment Optional

None of these Optional

Enter details from your EHIC

Country code Optional

Name Optional

Given name Optional

Date of birth

Personal identification number Optional

Identification number of the institution Optional

Identification number of the card Optional

Expiry date

How will your EHIC and S1 data be used?

By using your EHIC for NHS treatment costs your EHIC 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 or S1 information will be shared with Business Service Authority for the purpose of recovering your NHS costs from your home country.

You can help save lives as a blood or organ donor. Become someone’s lifeline. Visit www.nhsbt.nhs.uk/lifeline or call us on 0300 123 23 23

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Name

Prefix

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Name

First Middle Last

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Previous Surname (if applicable) Optional

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Gender

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Home Telephone Optional

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Mobile Number

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Do you content to be contacted via SMS?

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Previous Address

Street Address Optional Address Line 2 Optional City Optional Post Code Optional

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Enter Email Confirm Email

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Do you consent to be contacted Via email?

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Occupation Optional

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Next of Kin

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Do you have a next of kin?

(emergency contact person)

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Name

First Last

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Phone

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Relationship to you

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Previous GP

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GP Name

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Address

Street Address Address Line 2 City Post Code

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Other Details

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Country of Birth

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Ethnicity

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Religon Optional

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Communication Needs

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What is your main spoken language?

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Do you need an interpretor?

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Do you have any communication needs?

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Do you have a learning disability?

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Carer Details

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Do you have a Carer?

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Are you a Carer?

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Medical History

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Have you suffered from any of the following conditions?

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Any other conditions, operations or hospital admission details: Optional

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If you are currently under the care of a Hospital or Consultant outside our area, please tell us here: Optional

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Family History

Please record any significant family history of close relatives with medical problems and confirm which relative e.g. mother, father, brother, sister, grandparent.

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Relative Optional

i.e Parent, Sibling, Grandparent, Aunt/Uncle/Cousin etc

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Medical Problem Optional

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Allergies

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Please record any allergies or sensitivities

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Medication

Please check and include as much information about your current medication below.

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Please give us your previous repeat medication list if possible, a medication review appointment may be needed: Optional

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Your Lifestyle

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How many times a week do you exercise for more than 30 minutes?

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Alcohol

Please answer the following questions which are validated as screening tools for alcohol use: AUDIT–C QUESTIONS Please check the correct boxes and check your score. (Scores can be found to the right of your answer)

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How often do you have a drink containing Alcohol?

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Units

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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?

A score of less than 5 indicates lower risk drinking

Scores of 5 or more require the following 7 questions to be completed:

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Total Score:

4 or less

5 or more

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How often during the last year have you found that you were not able to stop drinking once you had started?

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How often during the last year have you failed to do what was normally expected from you because of your drinking?

How often during the last year have you needed an alcoholic drink in the morning to get yourself going after a heavy drinking session?

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How often during the last year have you had a feeling of guilt or remorse after drinking?

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How often during the last year have you been unable to remember what happened the night before because you had been drinking?

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Have you or somebody else been injured as a result of your drinking?

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Has a relative or friend, doctor or other health worker been concerned about your drinking or suggested that you cut down?

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Total Score?

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Smoking

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Do you smoke?

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How many cigarettes did/do you smoke a day?

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Would you like help to quit smoking?

For further information, please see:
www.nhs.uk/smokefree

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Height and Weight

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Height

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Weight

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Women's Health

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Are you Female?

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Do you use any contraception?

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Are you currently pregnant or think you may be?

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Expected due date

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Students

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.
For further information, please see:
www.nhs.uk/Livewell/Studenthealth

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Are you a student?

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I am less than 24 years old and have had two doses of the MMR Vaccination

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I am less than 25 years old and have had a Meningitis C Vaccination

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Electronic Prescribing

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If you would like your prescriptions to be sent electronically, please provide details of the pharmacy you would like to use: Optional

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PPG – Patient Participation Group

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Would you like to be involved in our Patient Participation Group?

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Blood and Organ Donation

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Blood Donation

I am already a blood donor

I wish to be a blood donor

I do not wish to be a blood donor

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Organ Donation

I am already registered as a donor

I wish to be a donor – all body part

I wish to be a donor – for these body parts:

I do not wish to be a donor

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Which organs would you like to donate: Optional

You can register Online

-OR-

You can call(030 0123 2323) and speak to an advisor who will send out a donor card.

I confirm that the information I have provided is true to the best of my knowledge.

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Name

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Date

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Your Health Record

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Do you consent to your GP Practice sharing your health record with other organisations who care for you?

I wish to give EXPRESS CONSENT for medication, allergies and adverse reactions only to be included in my Summary Care Record

I wish to give EXPRESS CONSENT for medication, allergies, adverse reaction and additional information to be included in the my Summary Care Record

I DO NOT CONSENT to have my Summary Care Record and do not wish to have one

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Do you consent to your GP Practice viewing your health record from other organisations that care for you?

Yes (recommended option)

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Your Summary Care Record (SCR)

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Do you consent to having an Enhanced Summary Care Record with Additional Information?

Yes (recommended option) Optional

No Optional

I wish to have online access to:

Please tick all that apply

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View & book appointments

View & request medication

Access my coded medical record (contains any medical codes that have been recorded)

Access my full medical record (contains medical codes and any free text that has been recorded)

Access my Summary Care Record

Complete online questionnaires

I wish to access my medical record and understand and agree with each statement:

Please tick all that apply

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I have read and understood the ‘Important Information’ section below

I will be responsible for the security of the information that I see or download

If I choose to share my information with anyone else, this is at my own risk

I will contact the practice as soon as possible if I suspect that my account has been accessed by someone without my agreement

If I see information in my record that it not about me, or is inaccurate I will log out immediately and contact the practice as soon as possible

Access to GP Online Services

Important Information – Please read before completing form below

If you wish to, you can now use the internet (via computer or mobile app) to book appointments with a GP, request repeat prescriptions for any medications you take regularly and look at your medical record online. You can also still use the telephone or call in to the surgery for any of these services as well. It’s your choice.

It will be your responsibility to keep your login details and password safe and secure. If you know or suspect that your record has been accessed by someone that you have not agreed should see it, then you should change your password immediately. If you are unable to do this for some reason, we recommend that you contact the practice so that they can remove online access until you are able to reset your password.

If you print out any information from your record, it is also your responsibility to keep this secure. If you are at all worried about keeping printed copies safe, we recommend that you do not make copies at all.

During the working day it is sometimes necessary for practice staff to input into your record, for example, to attach a document that has been received, or update your information. Therefore you will notice admin/reception staff names alongside some of your medical information – this is quite normal.

The definition of a full medical record is all the information that is held in a patient’s record; this includes letters, documents, and any free text which has been added by practice staff, usually the GP. The coded record is all the information that is in the record in coded form, such as diagnoses, signs and symptoms (such as coughing, headache etc.) but excludes letters, documents and free text.

Before you apply for online access to your record, there are some other things to consider. Although the chances of any of these things happening are very small, you will be asked that you have read and understood the following before you are given login details.

Forgotten history

There may be something you have forgotten about in your record that you might find upsetting.

Abnormal results or bad news

If your GP has given you access to test results or letters, you may see something that you find upsetting to you. This may occur before you have spoken to your doctor or while the surgery is closed and you cannot contact them.

Choosing to share your information with someone

It’s up to you whether or not you share your information with others – perhaps family members or carers. It’s your choice, but also your responsibility to keep the information safe and secure.

Coercion

If you think you may be pressured into revealing details from your patient record to someone else against your will, it is best that you do not register for access at this time.

Misunderstood information

Your medical record is designed to be used by clinical professionals to ensure that you receive the best possible care. Some of the information within your medical record may be highly technical, written by specialists and not easily understood. If you require further clarification, please contact the surgery for a clearer explanation.

Information about someone else

If you spot something in the record that is not about you or notice any other errors, please log out of the system immediately and contact the practice as soon as possible.

For further information, please see:
www.nhs.uk/NHSEngland/AboutNHSservices/doctors/Pages/gp-online-services.aspx

Please upload your photographic ID

Drop files here or

Max. file size: 50 MB.

Please upload your proof of address

Drop files here or

Max. file size: 50 MB.

Please note: Registrations will not be complete until a health check is completed. Someone from the practice will contact you within a week of completing the form to book you in for an appointment with a clinician.

Registration Form

PART A

Section 1 – Who is registering?

Section 2 – Details of patient registering

Section 3 – Patients under 18 years

Section 4 – Additional information

PART B

Section 5 – Patient health

PART C

Section 6 – Patients from abroad

Information on eligibility to free care outside the GP practice

Next of Kin

Previous GP

Other Details

Communication Needs

Carer Details

Medical History

Family History

Allergies

Medication

Your Lifestyle

Alcohol

Smoking

Height and Weight

Women's Health

Students

Electronic Prescribing

PPG – Patient Participation Group

Blood and Organ Donation

Your Health Record

Your Summary Care Record (SCR)

I wish to have online access to:

I wish to access my medical record and understand and agree with each statement:

Access to GP Online Services

Important Information – Please read before completing form below

Forgotten history

Abnormal results or bad news

Choosing to share your information with someone

Coercion

Misunderstood information

Information about someone else

Thank you for your feedback.