Online Pre-Registration

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Important Information

Please be advised that it is taking us 3 - 4 weeks to get patients registered due to the number of patients registering with ourselves. Please make sure you have at least 2 months of medication from your previous Practice to keep you going until you get registered with us. Thanks

Is this your first registration with a GP practice in the UK?*

Yes

Will you be in the area for more than 3 months?*

Yes

Please do not use this form, you must complete a temporary registration form.

Patient details

Gender*

Date of Birth*

Title*

First Names*

Surname*

Current Address and Postcode*

Telephone*

Mobile*

Email Address*

Community Health Index (CHI) Number*

NHS Number

Birth Town*

Birth Country*

Registered District of Birth

Mothers Maiden Name

Occupation*

Please help us trace your previous medical records by providing the following information

Name of Previous GP*

Address of Previous GP*

Your Previous Address*

This is usually the address when you were last registered with a GP

Are you from abroad?*

Yes

Your first UK address*

Date you first came to UK*

Are you returning from the Armed Forces?*

Yes

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

Regular

Reservist

Family Member

Address and Postcode before enlisting*

Service or Personnel Number*

Enlistment date*

Child Health Surveillance

I wish the child above to be registered with the named doctor for Child Health Surveillance

Nearest Chemist

I live more than 1 mile in a straight line from the nearest chemist

Chemist Difficulty

I would have serious difficulty in getting them from a chemist

Signatures

Signatures*

Patient's signature

Signature on behalf of patient

Please upload photo ID and proof of address*

Drop files here or

Max. file size: 128 MB.

Electronic Signature (Type your full name here)*

By completing the section above, I hereby sign this form electronically

NHS Organ Donor Registration

Would you like to join the NHS Organ Donor Register?*

Yes

Already on it

I want to register my details on the NHS Organ Donor Register as someone whose organs/tissue may be used for transplantation after my death.*

Any of my organs and tissue

Kidneys

Heart

Liver

Corneas

Lungs

Pancreas

NHS Blood Donor Registration

Would you like to join the NHS Blood Donor Register?*

Yes

Already on it

Tick here if you have given blood in the last 3 years

I have given blood in the last 3 years

My preferred address for donation is:

Allergies/Medicines*

Are you allergic to anything such as Penicillin or Aspirin?

Please list the names and doses of any medicines you are taking at present*

What is your preferred Pharmacy for prescriptions?*

Medical History*

Please enter any previous significant illness, accident or operations with the year they occurred

Have you had a breast check?*

Yes

When?*

Have you had a breast X-ray or Mammogram?*

Yes

When?*

Have you had any pregnancies?*

Yes

When?*

Have you had a cervical/cancer smear?*

Yes

When?*

Family History*

Please give details of any serious illness any of your relatives have suffered from especially your parents, brothers and sisters. If any of your parents, brothers or sisters have died could you please say how old they were when they died and what was the known cause of death

Do you smoke?*

Yes

Have you ever smoked?*

Yes

Daily consumption*

When did you stop?*

Do you drink alcohol?*

Yes

Consumption (units/week)*

Do you exercise?*

Yes

Type of exercise*

Do you use/ever have used drugs?*

Yes

Drugs used*

Do you look after someone?*

Yes

Please state your relationship to them*

Does someone look after you?*

Yes

Please state your relationship to them*

KIS Consent

Dear Patient,

In order to improve the information available to the out of ours service (GMEDS), Ambulance Service and Secondary Care (Hospital) it is now possible for some of the information held in GP records to be made available electronically to them by Key Information Summary (KIS). In order for this to happen, we need your permission to allow us to switch the transfer on. The information can only be accessed by those clinicians who require it. The information includes up to date medication lists and major health issues. This information is very important in an emergency and could reduce delays in treatment. If you are happy for this information to be shared, please complete the relevant section below

For patient

I give my permission for my records to be shared for the use of KIS

Name

First Last

Date of Birth*

Signature

Date

Next of Kin Name*

First Last

Next of Kin Address

Street Address Address Line 2 City County / State / Region Postcode Country

Next of Kin Phone*

For parent if applicable

I give my permission for the records of ............, for whom I am the parent, to be shared for the use of KIS

Parent Name

First Last

Parent Date of Birth

Signature

Date

For guardian if applicable

I give my permission for the records of ..........., for whom I hold Welfare Power of Attorney/Guardianship, to be shared for the use of KIS

Guardian Name

First Last

Guardian Date of Birth*

Signature

Date

Registration for ordering prescriptions online

Would you like to register for ordering prescriptions online?*

Yes

The email address you have already supplied will be used by your practice to send you notifications and reminders*

I consent

I do not consent

The mobile number you have already supplied will be used by your practice to send you notifications and reminders*

I consent

I do not consent

Signature

Date

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Online Pre-Registration

Patient details

Please help us trace your previous medical records by providing the following information

Signatures

NHS Organ Donor Registration

NHS Blood Donor Registration

KIS Consent

Registration for ordering prescriptions online

Opening Times

Useful Links

Vaccination and Wellbeing Hub

A-Z of Symptoms

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