New Patient Registration

If you would like to register with the practice please use this form.

To register a new patient you will need to live within our practice boundary.

New Patient Registration

New Patient Registration

Patient's details

Title *
Please use format dd/mm/yyyy
Sex *
Any correspondence will go to this address

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

Have you previously been registered with another GP?

Overseas Patients

Are you from abroad?
Please use format dd/mm/yyyy
Please use format dd/mm/yyyy

Armed Forces

Have you ever been registered with an Armed Forces GP?
Please indicate your Armed Forces status
Please use format dd/mm/yyyy
Please use format dd/mm/yyyy

Signature

NHS Organ Donor registration

Do you want to register your details on the NHS Organ Donor Register as someone whose organs/tissue may be used for transplantation after your death? *
Please tick the boxes that apply

Please tell your family you want to be an organ donor. If you do not want to be an organ donor, please visit www.organdonation.nhs.uk or call 0300 123 23 23 to register your decision.

NHS Blood Donor registration

Do you want to register your details on the NHS Blood Donor Register as someone who may be contacted and would be prepared to donate blood? *

All blood types are needed, especially O negative and B negative. Visit www.blood.co.uk or call 0300 123 23 23.

To be completed by the GP practice

Supplementary Questions

These questions and the patient declaration are optional and your answers will not affect your entitlement to register or receive services from your GP.

Patient Declaration - for all patients who are not ordinarily resident in the UK

Anybody in England can register with a GP practice and receive free medical care from that practice.

However, if you are not 'ordinarily resident' in the UK you may have to pay for NHS treatment outside of the GP practice. Being ordinarily resident broadly means living lawfully in the UK on a properly settled basis for the time being. In most cases, nationals of countries outside the European Economic Area must also have the status of 'indefinite leave to remain' in the UK.

Some services, such as diagnostic tests of suspected infectious diseases and any treatment of those diseases are free of charge to all people, while some groups who are not ordinarily resident here are exempt from all treatment charges.

More information on ordinary residence, exemptions and paying for NHS services can be found in the Visitor and Migrant patient leaflet, available from your GP practice.

You may be asked to provide proof of entitlement in order to receive free NHS treatment outside of the GP practice, otherwise you may be charged for your treatment. Even if you have to pay for a service, you will always be provided with any immediately necessary or urgent treatment, regardless of advance payment.

The information you give on this form will be used to assist in identifying your chargeable status, and may be shared, including with NHS secondary care organisations (e.g. hospitals) and NHS Digital, for the purposes of validation, invoicing and cost recovery. You may be contacted on behalf of the NHS to confirm any details you have provided.

Please select one of the following boxes:

I declare that the information I give on this form is correct and complete. I understand that if it is not correct, appropriate action may be taken against me.

A parent/guardian should complete the form on behalf of a child under 16.

European Economic Area(EEA) Country

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?
Do you have a non-UK European Health Insurance Card (EHIC) or Provisional Replacement Certificate (PRC)?

If you are visiting from another EEA country and do not hold a current EHIC, PRC or S1, you may be billed for the cost of any treatment received outside of the GP practice, including at a hospital.

Please use format dd/mm/yyyy
Do you have an S1 (e.g. are you retiring to the UK or have you been posted here by your employer for work or live in the UK but work in another EEA member state)?

Please give your S1 form to the practice staff.

How will your EHIC/PRC/S1 data be used? By using your EHIC or PRC for NHS treatment costs your EHIC or PRC data and GP appointment data will be shared with NHS secondary care (hospitals) and NHS Digital solely for the purposes of cost recovery. Your clinical data will not be shared in the cost recovery process.

Your EHIC, PRC or S1 information will be shared with The Department for Work and Pensions for the purpose of recovering your NHS costs from your home country.

Sharing and receiving data

Your patient record will be held securely and confidentially on our electronic system. If you require treatment in another NHS healthcare setting such as an Emergency Department or Minor Injury Unit, those treating you would be better able to give you appropriate care if some of the information from the GP practice were available to them.

This information is your summary care record.

Please view the Summary Care Record page so you can make informed decisions on the next section.

NHS Summary Care Record

Your choice for SCR

SCR with Additional information can be added (upon request to your GP practice) which includes:

  • Significant problems (past and present)
  • Significant procedures (past and present)
  • Anticipatory care information
  • End of life care information – as per EOLC dataset ISB 1580
  • Immunisations

Gloucestershire shared health and social care information (JUYI/EMIS Shared) (Used locally across Gloucestershire)

Your Choice for Gloucestershire shared health and social care information (JUYI)

SMS texting service

We offer a Text Messaging service to remind patients about their future appointments along with important announcements and information about your care.

This service is only available if you have a valid mobile number and if you are aged 16 and over.

If you are over 16 the mobile number must be yours and not a parent or guardians.

Title
Please use format dd/mm/yyyy
By agreeing to this you are agreeing that your phone is personal to you and any data you receive regarding your results will be accessed by only you or you are happy for those who access your phone to see these results. You will not receive every result by text, sometimes we may send a text message to ask you to call the surgery to arrange an appointment regarding your results. If you have not heard anything from us and you are concerned please still call the surgery as usual

I confirm that the above details are correct and true. 

If you are signing on behalf of the patient above, please enter your details below and your relationship to the patient (e.g. parent, guardian, attorney).

New Patient Questionnaire

A parent or guardian should complete this form on behalf of a child under 16

Female patients aged 12 and over from abroad – Do you know your rubella status? If you have no record of this vaccination please book and appointment with our practice nurse to have this vaccination

Do you speak English?
Do you read English?

Past Medical History

Please list any immunisations/vaccinations you have had or are outstanding
Sight
Hearing

Lifestyle

Please state how much exercise and what type you do per week (e.g. none, inactive, gentle, moderate, vigorous, routinely)
(e.g. good, poor, moderate, vegetarian, vegan, meat eater)

Alcohol Consumption

How often do you have a drink that contains 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? *

A total of 5+ indicates a higher risk drinking. An overall score of 5 or above is AUDIT-C positive.

Smoking

Smoking Status
Please use format dd/mm/yyyy
Please use format dd/mm/yyyy
Are you interested in advice on how to quit?

Allergies

Do you have any drug allergies?
Do you have any other allergies?

Adult Females

Please use format dd/mm/yyyy
Have you had a hysterectomy?
Do you still have your ovaries?

Carers

Do you have a carer?
Are you a carer for someone?

Emergency Contact

Are they your next of Kin?

Consent

Would you like to set up a password to give consent for a person you trust to access results/medical information on your behalf?

Online Services

You can register for online services through our administration office on the surgery website. This will help you manage your healthcare and order repeat prescriptions and make appointments at the click of a button. If you wish to benefit from this service please register after completing this form as you will then only need to bring your ID in once.

Declaration

*