• Personal Information

  • Date of Birth*
     / /

  • Parents/Guardian

  • Contact Details

  • Preferred method of communication*
  • Do you consent to the receipt of text messages and emails in relation to your medical care, i.e. appointment reminders, test results, information regarding flu clinics or other clinic relevant to your medical care?*

  • Armed Forces

  • Have you either served in the UKarmed forces and/or been registered with a Ministry of Defence GP in the UK or overseas (this includes regular, reservist, veteran, or family member)?*

  • Gender Identity

  • Gender*
  • Is your gender identity the same sex as you were assigned to at birth?
  • Which of the following best describes how you think of yourself?

  • Language, Communication and Accessible Information

  • Do you require a language interpreter?*
  • Do you have any hearing difficulties?*
  • Do you require a BSL interpreter?*
  • Do you consider yourself to have a disability or neuro diversity?*

  • Carers

  • Do you have a carer?*
  • Are you a carer?

  • Next of Kin

  • Please be aware - next of kin information is held only for use in a critical emergency only.

  • Smoking Status

  • Have you ever smoked?*
  • If you are a current smoker, would you like our team to contact you regarding stopping smoking?

  • Height and Weight

  • Alcohol Intake

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  • 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?
  • How often during the last year have you failed to do what was normally expected from you because of your drinking?
  • How often during the last year have you been unable to remember what happened the night before because you had been drinking?
  • Has a relative or friend, doctor or other health worker been concerned about your drinking or suggested that you cut down?

  • Medical History

  • Do you have or have had any of the following if yes please provide the us with as much information on the condition as you can – Date of diagnosis, treatment/medication taken.

  • Medications

  • Please be aware, if you do take prescribed medication you will need to book an appointment with a GP before anymore can be prescribed. Appointments can be booked up to two weeks in advance. It takes three working days from medications being ordered before you can collect, please therefore you have an adequate supply of your medications.

  • Allergies

  • Hospital Care

  • Are you currently receiving care from a hosptial consultant?

  • National Screening

  • Date of last cervical screen (smear) if known
     / /
  • Date of last mammogram (breast screen) if known
     / /

  • Identification Verification

  • We require one document to confirm proof of name this can be any of the following:

    • Birth Certificate
    • Marriage Certificate
    • Driving Licence (Valid)
    • Passport (Valid)
    • Deed Poll

  • We require one document to confirm proof of address:

    • Utility Bill
    • Council Rent Book
    • Bank Statement
    • Credit Card Statement
    • Letter from Benefits Agency

  • Please Note:

    • We ask all new patients to present the surgery with documentation to verify their identity.
    • None of your verification documents are held on your records and are used for registration purposes only.
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