New Patient Application Form

Name*

First Name(s)Surname

Birth Details*

Date of BirthCountry of Birth

Current Address*

Current Postcode*

Previous Address, if recently moved;

Mobile Phone Number

Consent to text / sms*

YesNo

Home phone number

Email address

example@example.com

Dependent children to join? - please add below;

Child 1

NameAge & Date of Birth

Child 2

NameAge & Date of Birth

Child 3

NameAge & Date of Birth

Previous GP/Surgery name & Town*

Main spoken Language

Interpreter Required?

YesNo

Date you first entered the UK?

Do you have any requirements that help you to access information? i.e Braille, EasyRead, Large print etc

How often do you have a drink that contains alcohol?

How many units do you have on a typical day when you are drinking? (pint of beer = 2.3 units, 250ml glass of wine = 3 units, a bottle of wine = 9 units, single spirit and mixer = 1 unit

How often do you have 6 or more units on one occasion?

Score

Thank you for completing a New Patient Application Form. The Doctor will now check the form and either accept or decline your application. Please call into the surgery, or telephone 01484 500921, after 2 working days to see if your application has been accepted. You will then be asked to make a New Patient Health Check appointment with the Health Care Assistant. You will not be able to see the GP until you have had this check. Please bring any medication you use and a urine sample (bottles available from reception) to your Health Check appointment. We only keep these forms for 2 weeks, so if you don't get back in touch we assume you have registered elsewhere and will securely destroy your form.

If you fail to attend your New Patient Health Check Appointment you will not be registered here as a patient. Unfortunately, if you miss your New Patient Health Check appointment we will not be able to make you a new appointment, experience tells us that if patients fail to attend appointments before they are registered, they continue to miss them once they are patients.

PLEASE NOTE: MASKS ARE REQUIRED IN OUR BUILDING WHEN ATTENDING FOR APPOINTMENTS