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.

Please note we may refuse to register you for the following reasons:

you live outside the practice boundary, and they are not accepting patients from out of their area
you have been removed from that GP surgery register before
it's a long way from your home and you need extra care, for example home visits

Please use the link below to check if your postcode is within the practice area, or alternatively use the map displayed on this webpage.

https://experience.arcgis.com/experience/c5dfab9f267944d2a9d68e8b0469568b/page/public?data_filter=dataSource_1-GI2598_Bdys_PUBLIC_9878%3APracticeCode%3D%27L83137%27

Patient's details

Please complete the text boxes and tick where appropriate

Your title

Mrs

Miss

Surname

First name(s)

Previous surname

Your date of birth

Sex

Male

Female

Birth town

Birth country

Telephone

NHS No.

An NHS number is a 10-digit number, like 485 777 3456. If known, please enter your NHS number in the field below. You can find more information on the NHS website

Home address

Postcode

I am a student at:

If applicable, please enter the name of the educational institution you are attending in the field below

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

Your previous address in UK

Name of previous GP while at previous address

Address of that Doctor

If you are from abroad

Your first UK address where registered with a GP

If previously resident in UK, date of leaving

Date you first came to live in UK

Were you ever registered with an Armed Forces GP

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

Regular

Reservist

Veteran

Family Member (Spouse, Civil Partner, Service Child)

Address before enlisting

Postcode before enlisting

Service/Personnel No.

Enlistment date

Discharge date (if applicable)

If you need your doctor to dispense medicines and appliances

Do you need your doctor to dispense medicines and appliances?

I live more than 1.6km in a straight line from the nearest chemist

I would have serious difficulty in getting them from a chemist

Are you a patient?

I am a patient

I am filling the form on behalf of a patient

Date

Please enter the date of submitting the application below