Register as a new patient form

If you would like to become a patient at our surgery, you will need to register your details with us.  

Complete the form below to register as a new patient at the surgery. The form should take less than ten minutes to complete. If you need any help, please call the surgery for us to help you.

To register as a patient at the practice  you will need to live within the Practice Boundary.

All newly registered patients are allocated a named GP who is responsible for patient overall care at the practice. Patients are welcome to contact the practice if they wish to know who their allocated named GP is. If a patient has a specific preference of who they wish their GP to be, the practice will make reasonable efforts to accommodate this request.

Once you have submitted this form you will need to provide the practice with suitable proof of ID (Passport, Driving Licence, Bank Statement or Utility bill). We are not currently requiring to see proof of ID at this time due to COVID restrictions. 


Any responses we send will go to this email address.
Can we contact you by text?
Can we contact you by email?
Please specify the ethnic group you consider you belong to
Do you speak English?
Do you read English?

Please enter details of your emergency contact below

Are they your next of kin?
Do you give us permission to discuss your medical records with them?


Do you have any allergies?

Previous details

Have you been previously registered with another surgery in the UK?

If you are from abroad

Registering for the first time in the UK
Please include postcode.
If you are returning from abroad (Previously been a resident in the UK)
If you are returning from abroad (Previously been a resident in the UK)

Were you ever registered with an Armed Forces GP

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

EPS (Electronic Prescription Service)


Smoking Status

Alcohol Consumption diagram


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

Adult Females only

Was it done at
Have you had a hysterectomy?
Do you still have your ovaries?

Medical history

Please include dates.
Please include dates.
Please include dates.
Please include dates.
Do you have any communication needs?

The Department of Health has advised that all patients of 75years and older have a named and accountable GP to oversee their care. Please ask the name of the GP assigned to oversee your care. Please note this does not prevent you from seeing the GP of your choice.

Supplementary question

Do you live in another EEA country, or have moved to the UK to study or retire, or live in the UK but work in another EEA member state?

Summary Care Record

The SCR is an electronic record of important patient information, created from GP medical records. It can be seen and used by authorised staff in other areas of the health and care system involved in the patient's direct care.
If you are registered with a GP practice in England your SCR is created automatically, unless you have opted out. 98% of practices are now using the system. You can opt-out of the SCR by ticking the box below.

Including Additional Information to your Summary Care Record

You can ask your GP to add additional information to your record. This additional information will improve the flow of information across the health and care system, increase safety and efficiency and improve care and It's particularly useful for people with complex or long term conditions, or patients reaching end of life.

- significant facts about your medical history – past or present
- information about any long-term conditions you have
- your immunisation history
- how you would like to be treated
- what support you might need
- who should be contacted for more information about you.

Further information can be found at: or phone NHS Digital on 0300 303 5678.

If you would like to add extra information to your Summary Care Record, Please tick the box below:

What happens to my information?

Personal and medical information about patients registered at this practice are primarily kept electronically, although some is kept in paper form. Some information will be sent to hospital consultants and other health professionals to whom you are referred by your GP in order to provide continued healthcare and obtain treatment for you.

We sometimes use accredited suppliers for our communication with you, for example when we send recall letters for review clinics or medication reviews. All suppliers we use are checked carefully to ensure they comply with strict confidentiality protocols.

To ensure the security of all patient information, all staff that has access to your records is covered by confidentiality clauses in their contracts and the Data Protection Act and the Freedom of Information Act. Our guiding principle is that we hold your records in strict confidence.

NHS Organ Donor registration

If you wish your medical records to be marked that you are willing to donate organs/tissue for transplantation after your death; please tick:
Write your full name if you wish your medical records to be marked that you are willing to donate organs/tissue for transplantation after your death

If you would like to join the NHS Organ Donation Register please visit their website on:

NHS Blood Donor registration

If you would like to join the NHS Blood Donor Register as someone who may be contacted and would be prepared to donate blood, please visit their website on: or call direct on 03001232323