HOW DO I...
REGISTER?

If you wish to become a patient at the surgery you will be required to fill in some forms giving us information about yourself and your previous medical and family history. You will also be offered a new patient health check with the practice nurse.

ONLINE REGISTRATION

To register online please complete the form below-

REGISTER DETAILS   Title: Please select Mr Mrs Miss Dr Proff Other (please specify) Date of Birth (DD/MM/YYYY): Town & country of Birth: NHS no. (if known): Sex: Please select Male Female Surname: First Names: Home Telephone: Mobile Telephone: Work Telephone: How you describe your ethnic origin? Email Address: Address:   Postcode: Are you a carer for a sick/elderly person(s)? Please select Yes No Do you have a carer? Please select Yes No

Questionnaire Marital Status Religion Have you been registered at this surgery before? Please select Yes No What is your first language? Do you require an interpreter? Please select Yes No Occupation OR Name and Address of School   Occupation School Name   Address 1 Address 2 Postcode Next of Kin (Please supply the name, address, telephone number and relationship) Name Address 1 Telephone Number Address 2 Relationship Postcode

Family History Do any members of your immediate family have any of the following? (i.e. mother, father, brothers, sisters, grandparents) Illnesses Family member, age diagnosed and details Heart Disease Please select Yes No Stroke Please select Yes No Diabetes Please select Yes No Asthma Please select Yes No Cancer Please select Yes No High Blood Pressure Please select Yes No Glaucoma Please select Yes No

Medical Information List any illness you have had in the past or are taking regular medication for at present. Illness 1 Medication 1 Illness 2 Medication 2 Illness 3 Medication 3 Other Illnesses or Medication Are you currently under the care of any specialist? (If 'YES', please give name, speciality and hospital.) Please select Yes No Name Speciality Hospital Are you on any regular medication? (If 'YES', please list drug name and dosage prescribed). Please select Yes No Drug 1 Dosage 1 Drug 2 Dosage 2   Drug 3 Dosage 3   Other Drugs/ Dosage Are you allergic to any drugs or medicines? (If 'YES', please list drug and the reaction it caused.) Please select Yes No Drug 1 Reaction 1 Drug 2 Reaction 2   Drug 3 Reaction 3

About Yourself Do you smoke? Please select Yes No If 'YES', how many do you smoke a day? Are you an ex-smoker? Please select Yes No If 'YES', when did you stop? If you smoke and would like some help in giving up, please contact "Quitters" on 023 8051 5221, or make an appointment with your doctor. Female Only What form of contraception do you use? When did you have your last cervical smear?

Previous medical records Your previous address in the UK   Postcode Name of your previous doctor at that address Address of previous doctor Are from abroad? Please select Yes No Your first UK address where registered with a GP If previously resident in the UK, date of leaving Date you came first came to the UK Are returning from the Armed Forces? Please select Yes No Address before enlisting   Service/Personnel No.:   Enlistment date: NHS Organ Donor Registration I would like to join the NHS Organ Donor Register as someone whose organs may be used for transplantation after my death. Please select Yes No Please check as appropriate:- Kidneys Heart Liver Corneas Lungs Pancreas Any part of my body CONFIDENTIALITY - TERMS AND CONDITIONS: The internet is not secure, and the transmission of this data is entirely at the patient's own risk. The practice accepts no responsibility for breaches in confidentiality resulting from patients' transmissions. I accept the terms and conditions above On receipt of your completed application, we will send you a pack with details of our practice and contact you to organise a new patient check.