New Patient Registration

"*" indicates required fields

Step 1 of 2

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I am completing this form for:*

Myself

My partner that lives with me

My child

Someone else

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Singular

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Possessive

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Verb

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Pronoun

Hidden

Self Pronoun

Hidden

Do Does

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Has Have

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Is Are

Patient Details

What is name?*

Title First name Middle Surname

Previous surname(s)

(If relevant)

NHS Number

(If known)

Date of Birth*

Day

Month

Year

Marital Status

Which of the following options best describes ?

Heterosexual/Straight

Lesbian/Gay

Bisexual

Other

Which of the following best describes how think of ?*

Female (including trans women)

Male (including trans men)

Non-binary

Other

Is gender identity the same as the gender were given at birth?*

Yes

Preferred Pronouns

Town and Country of Birth*

Home Address*

If the address is not in our area your registration will be rejected.

If not have a permanent address then you can use a temporary address, such as a day centre or a friend's address. If you have no other options then please ring the practice and we can discuss this with you.

Street Address Address Line 2 City Postcode

Mobile Phone*

Can we use this number for text messages?

(For example, appointment reminders)

Yes, I consent

Email Address

Previous Medical Records

Please help us locate the correct medical records with the following information.

Previous Address in the UK

If recently moved to their current home from another address in the UK.

Street Address Address Line 2 City Postcode

Previous NHS Practice and GP

The practice were previously registered with, and the named GP there.

If from abroad

First UK address

The first address in the UK where registered with a GP.

If previously resident in the UK, the date of leaving

Date first came to live in the UK

Armed Forces

Have ever been registered with an armed forces GP?

Please indicate if ever served in the UK Armed Forces and/or been registered with a Ministry of Defence GP in the UK or overseas.

Yes

In what capacity?

Regular

Reservist

Veteran

Family member (spouse, civil partner, service child)

Service or personnel number

Address and postcode before enlisting

Enlistment date

Discharge date

Ethnicity

What is ethnic group?*

Please tick one box that best describes ethnic group or background from the options below.

White: British, Irish, Irish Traveller, Traveller, Gypsy/Romany, Polish, any other white background

Mixed: white and black Caribbean, white and black African, white and Asian, any other mixed background

Asian or Asian British: Indian, Pakistan, Bangladeshi, any other Asian background

Black and black British: Caribbean, African, Somali, Nigerian, any other Black background

Other ethnic group: Chinese, Filipino, Any other ethnic group

Not disclosed

Spoken language(s)

Is any communication support required?

Interpreter

Sign Language interpreter

Deaf-blind interpreter

Advocate

Speech to text reporter

Other interpreter/accessible support

Further information

Do have difficulty reading or writing?

Yes

How would like to be communicated with?

a carer?

Yes

What is the name of the person care for?

Are they already registered with us?

registered disabled?

Yes

Do or immediate family have a social worker?

Yes

Do have a carer?

Yes

Carer's name and contact details

Do give consent for their carer to discuss their medical record?

Yes

Is anyone in household already registered at this practice?

Yes

Please give their name(s)

Note: Children under 10 must have an adult from their household registered at the practice.

You've indicated that you are registering your child with our practice. Please tell us some more about them.

Your child's school/nursery name

Does your child have any visual or speech difficulties?

Health Screening Questions

We collect this information to better support you and to ensure a smooth transition to us from your last registered practice. If you choose not to fill out this information here, we will ask you to fill out a form for the same information during your new patient check, so you might find it quicker and easier to fill out this information now.

Has anyone in direct family had any of the following?

Direct family: parents, grandparents, brothers or sisters but NOT husband or wife.

Select all that apply.

Heart attack

A stroke

Diabetes

Asthma

Cancer

ever had one of the following?

Heart attack

A stroke

Diabetes

Asthma

Cancer

Do have any allergies?

If so, please list them.

on any current medication?

Yes

Please give details, or upload a photo of repeat medication request slip in the next question

Upload photo of repeat medication request slip

Drop files here or

Accepted file types: jpg, jpeg, png, gif, pdf, Max. file size: 15 MB, Max. files: 3.

Are up to date with childhood vaccinations?

NHS Vaccination Schedule (link opens in a new tab)

Yes

Have ever been admitted to hospital?

Yes

Please provide more details

Do any medical problems that you regularly see a medical professional about?

Yes

Please provide more details

Do smoke?*

Never smoked

Ex smoker

Current smoker

Social smoker (occasionally)

Exposed to at work or at home but not a smoker

How many per day do smoke?*

How many per day did smoke?*

Would like help to quit smoking?*

Yes

Third Choice

If are aged between 15-24, would you like an RUclear Chlamydia test?*

Yes

Not aged between 15-24

Alcohol Consumption

How often do have a drink containing alcohol?

Never

Monthly or less

2-4 times per month

2-3 times per week

4+ times per week

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

1-2

3-4

5-6

7-9

10+

How often have had 6 or more units if female, or 8 or more if male, on a single day/occasion in the last year?

Never

Less than monthly

Monthly

Weekly

Daily or almost daily

Hidden

Alcohol AUDIT-C screening score

More about alcohol consumption

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

Never

Less than monthly

Monthly

Weekly

Daily or almost daily

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

Never

Less than monthly

Monthly

Weekly

Daily or almost daily

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

Never

Less than monthly

Monthly

Weekly

Daily or almost daily

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

Never

Less than monthly

Monthly

Weekly

Daily or almost daily

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

Never

Less than monthly

Monthly

Weekly

Daily or almost daily

or somebody else been injured as a result of drinking?

Yes, but not in the last year

Yes, during the last year

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

Yes, but not in the last year

Yes, during the last year

Hidden

Alcohol AUDIT screening score

Hidden

Alcohol AUDIT-C+AUDIT score

(Refer to Brief Intervention (IBA) pathway)

Completing your registration

Please attach a form of photo ID and proof address.*

Acceptable forms of ID: Passport, driving licence, birth certificate, utility bill, council tax statement, bank statement, HC2 certificate, rough sleepers' identity badge, hostel or accommodation registration or mail forwarding letter

Drop files here or

Max. file size: 512 MB, Max. files: 3.

If do not ID that fulfils the above criteria, please tick here.

I do not have any ID

Name

This field is for validation purposes and should be left unchanged.

New Patient Registration

Patient Details

Previous Medical Records

If from abroad

Armed Forces

Ethnicity

Further information

Health Screening Questions

Alcohol Consumption

More about alcohol consumption

Completing your registration

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