New Patient Registration

Please allow 3 working days for the practice to process this form.

Once you have complete this form you will need to come into the practice with photographic ID and proof of address to complete your registration.

Residents from our local area are very welcome to register with the practice.

We also understand, that for some people, it may be more convenient to register with a practice, that might for example be closer to your place of work.

Therefore, we are pleased to welcome applications for registration from patients that live outside of our main catchment area. If you live outside of our main catchment area, and you require a home visit (if you are too ill to attend the surgery), then this service is available from NHS 111.

To register you can complete the on-line registration form below. Alternatively, you can collect them in person from Rush Hill Surgery or Weston Surgery.

When registering with the practice, please bring two forms of ID, one of which must be photographic and the other must have proof of address.

When you join the practice, we are pleased to be able to provide you with an on-line user name and password that will allow you to book, check and cancel appointments online as well as request repeat medication. Please bring some photographic ID to reception to allow us to issue you with online log-in details.

Newly registered patients with children under 5 year old are asked to provide us with details of previous immunisations your child may have had. It is extremely important that these are recorded in the patient’s record.

When you register with the practice, we allocate you a named GP. This GP will be responsible for your overall care. Continuity of care to our patients is important to us, and we encourage our patients to see their allocated or ‘Usual’ GP wherever possible. You can of course choose to see a different GP to your allocated GP, and we are very happy for to swap your allocated GP, should you prefer another GP at the practice to be you ‘Usual Doctor’. If you would like to swap, please either let the doctor of receptionist know.

We ask all newly registered patients to make an appointment for a ‘New Patient Health Check’. This appointment will be with one of the nursing team, where they will have the opportunity to discuss your medical history, and for the nurse to carry out come simple tests which provide us with important baseline information.

New Patient Registration

• Patient Details
• Health Information
• Health Information
• Further Information

0% Complete

1 of 4

I am registering a child under 5

Patient's Details

Title *

Mr

Mrs

Miss

Ms

Other

Please specify:

Surname: *

Previous Surnames:

First Name(s) *

Date of Birth: *

Please use this date format: DD/MM/YYYY.

Gender *

Male

Female

Unspecified

NHS Number:

Home Address: *

Postcode: *

Home Phone Number:

Mobile Phone Number:

Work Phone Number:

Email Address: *

Any responses we send will go to this email address.

Can we contact you by text?

Yes

No

Can we contact you by email?

Yes

No

Nationality

Please specify the ethnic group you consider you belong to:

White British

White Irish

Other White

Black Caribbean

Black African

Other Black

Black Caribbean and White

Black African and White

Other Mixed

Indian

Pakistani

Bangladeshi

Other Asian

I do not wish to state

Other ethnic group

Please state:

Do you speak English?

Yes

No

Do you read English?

Yes

No

First Language:

Town and Country of birth: *

Emergency Contact

Full Name:

Relationship to you:

Phone Number:

Are they your Next of Kin?

Yes

No

Do you give us permission to discuss your medical records with them?

Yes

No

Allergies

Do you have any allergies?

Yes

No

Please specify what you are allergic to, what happens and when you had your first reaction:

Previous Details

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

Yes

No

Previous address in UK: *

Please include postcode.

Name and address of previous GP: *

If you are from abroad

Registering for the first time in the UK

Date you came to live in the UK:

Please use this date format: DD/MM/YYYY.

Your first UK address where registered with a GP

Please include postcode.

If you are returning from abroad

Previously been a resident in the UK

Date you left the UK:

Please use this date format: DD/MM/YYYY.

Date you returned to the UK:

Please use this date format: DD/MM/YYYY.

HM Armed Forces Veteran

Have you ever done Military Service?

Yes

No

If you need your doctor to dispense medicines and appliances *

*Not all doctors are authorised to dispense medicines

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

I would have serious difficulty in getting them from a chemist

Carers

Do you have a carer?

Yes

No

Are you a carer for someone?

Yes

No

Name of carer:

Phone Number:

Address:

Do you give us permission to discuss your medical record with your carer?

Yes

No