How to register

We have an open list and welcome requests for registration from patients living in the N18 postcode or moving into the practice area.

If you live in the N18 postcode and wish to register a new born baby please attend the surgery for further advice. Please do not use the online form.

You can register by either:

COMPLETING THE ONLINE REGISTRATION FORM
New Patient Registration Combined Form v1.001
Patient's details
Title(Required)
Mr
Mrs
Miss
Ms
Mx
Other
First names(Required)
Surname(Required)
Previous surnames
Date of birth(Required)
Day
Month
Year
NHS Number
Get help to find your NHS number online
Town and country of birth(Required)
House name/number(Required)
Please use your current address
Street name(Required)
Please use your current address
Postcode(Required)
Please use your current address
Home phone number
Mobile phone number
Preferred phone number(Required)
Alternative phone number
Do you consent to us sending you text messages relating to your care e.g. appointment reminders and when we need you to contact the surgery?(Required)
Yes
No
Email address(Required)
Enter Email Confirm Email
Can we contact you by email?(Required)
Yes
No
Are you a student?(Required)
Yes
No
Are you registering a child?(Required)
Yes
No
Does this child attend a Local Authority School/Nursery?(Required)
Yes
No
Please state which School/Nursery they attend
Please provide a contact number for the School/Nursery
Please give the name/s of those who have parental responsibility(Required)
Relationship to child
Phone number/s of those with parental responsibility
Legal status if the child is living with foster carers
Register as a New Patient
The answers you give will be sent securely to your practice to be reviewed by the appropriate team member in the practice. Your answers will be used by your practice to identify you and to make decisions about your care. Please answer all questions as accurately as possible.(Required)
I consent to my practice to use my data as described
Please help us trace your previous medical records by providing the following information
We are now going to ask you some questions to help trace your health records from your previous GP in the UK. If you are new to the UK we will create a new health record for you. It is important to fill out as much detail below as possible.
Name and address of previous GP in UK
(If you are not new to the UK)
Please provide your previous address in UK
Please include your postcode
If you are from abroad
Registering with the NHS for the first time in the UK
Date you came to live in the UK
Day
Month
Year
First UK address where you registered with a GP
Please include postcode
If you are returning from abroad
Previously been registered with the NHS in the UK
Date you left the UK
Day
Month
Year
Date you returned to the UK
Day
Month
Year
Supplementary questions
Are you ordinarily resident in the UK?
Yes
No
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. Alternatively for more information go to Visiting or moving to England.
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 statements:
I understand that I may need to pay for NHS treatment outside of the GP practice
I understand I have a valid exemption from paying for NHS treatment outside of the GP practice. This includes for example, an EHIC, or payment of the Immigration Health Charge (“the Surcharge”), when accompanied by a valid visa. I can provide documents to support this when requested
I do not know my chargeable status
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.
Type your full name to show you agree to this declaration
On behalf of
Relationship to child
Today's date
Day
Month
Year
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?
For a list of EEA countries visit: www.gov.uk/eu-eea
Yes
No
Do you have a non-UK European Health Insurance Card (EHIC) or a Provisional Replacement Certificate (PRC) ?
Yes
No
Country code
Name
Given names
Date of birth
Day
Month
Year
Personal Identification Number
Identification number of the institution
Identification number of the card
Expiry date
Day
Month
Year
PRC validity period (a) From:
Day
Month
Year
PRC validity period (b) To:
Day
Month
Year
Do you have an S1 Form?
I have an S1 form (e.g. you are retiring to the UK or you have been posted here by your employer for work or you live in the UK but work in another EEA member state). If you have an S1 form, please give this to the practice staff.
Yes I have an S1 form
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.
Demographics
Anyone in England can register and consult with a GP without charge. A practice cannot refuse an application on the grounds of race, ethnicity, gender, age, marital status, religion, sexual orientation, appearance, disability, medical condition or immigration status. Any demographic information you choose to provide will be used to help us ensure that we deliver the highest quality care to all.
Marital Status
Single, never married
Married
Divorced
Civil partnership
Widowed
Separated
Prefer not to say
Sex and gender identity - Which one of the following best describes you?
Female
Male
Intersex
Non-binary
Prefer to self describe
Prefer not to say
Is the gender you identify with the same as your sex registered at birth?
Yes
No
Prefer not to say
Which of the following options best describes how you think of yourself?
Heterosexual or Straight
Gay or Lesbian
Bisexual
Do not know or not sure
Prefer to self describe
Prefer not to say
Please specify the ethnic group you consider you belong to:
Arab
Asian
Black
Mixed/Multiple
White
Prefer not to say
Other
Asian
Bangladeshi
Chinese
Indian
Pakistani
Other
Black
African
Caribbean
Other
Mixed/Multiple ethnic groups
White and Asian
White and Black African
White and Black Caribbean
Other
White
English, Welsh, Scottish, Northern Irish or British
Gypsy or Irish Traveller
Irish
Other
What is your main religion?
No religion
Christian (including Church of England, Catholic, Protestant, and all other Christian denominations)
Buddhist
Hindu
Jewish
Muslim
Sikh
Prefer not to say
Other
Communication needs
Do you speak English?(Required)
Yes
No
Do you read English?(Required)
Yes
No
What is your main spoken language?
Are you a British Sign Language user?
Yes
No
Do you have any specific information or communication needs?(Required)
Yes
No
Please specify how we can meet your information or communication needs (for example large print, Braille, easy read)
Do you have any accessibility needs?(Required)
Yes
No
Please specify your accessibility needs and how we can help:
Disability
Do you have an impairment, health condition or learning difference that has a substantial or long term (over a year) impact on your ability to carry out day to day activities? (Tick all that apply)
No known impairment, health condition or learning difference
A long standing illness or health condition such as cancer, HIV, diabetes, chronic heart disease, asthma, or epilepsy
A mental health impairment, such as depression, schizophrenia or anxiety disorder
A physical impairment or mobility issues, such as difficulty using your arms or using a wheelchair or crutches
A learning difficulty
Neuro-diverse e.g. dyslexic, dyspraxic or AD(H)D
Deaf or hearing impaired
Blind or have a visual impairment uncorrected by glasses
An impairment, health condition or learning difference that is not listed above
Prefer not to say
Were you ever registered with an Armed Forces GP
Have you served in the UK Armed Forces and/or been registered with a Ministry of Defence GP in the UK or overseas?
Yes
No
Please provide your UK address before enlisting:
Service or Personnel number
Enlistment date
Day
Month
Year
Discharge date
Day
Month
Year
Immigration status
What is your current immigration status?
Regardless of immigration status, you can still register and consult with a doctor at a GP surgery without charge. Please tick if either of the following apply.
I am currently seeking asylum
I have been refused a claim to asylum in the UK
Carers
Do you have caring responsibilities?
None
Primary carer of a child/children (under 18)
Primary carer of disabled child/children
Primary carer of disabled adult (18 and over)
Primary carer of older person
Secondary carer (another person carries out the main caring role)
Prefer not to say
Who do you care for?
Do you live at the same address?
Yes
No
Are they registered at this practice?
Yes
No
Do you have a carer?
Yes
No
Name of carer
Address
Phone number
Do you give us permission to discuss your medical record with your carer?
Yes
No
Are you or have you ever been a looked after child?(Required)
Yes
No
A child who has been in the care of their local authority for more than 24 hours is known as a looked after child/child in care.
Do you or your family have a social worker?(Required)
Yes
No
Please give the name and contact details of the social worker
Please give the names of any other adults living in the family home
Emergency contact
Title
Mr
Mrs
Miss
Ms
Mx
Other
Full name
Relationship to you
Phone number
Are they under 16?
Yes
No
Please provide the name of the school they attend:
Are they at the same address as you?
Are they your next of kin?
Yes
No
Do you give us permission to discuss your medical records with them?
Yes
No
Your health
What is your height?
What is your weight?
Smoking status
Current smoker
Ex-smoker
Never smoked
What do you smoke?
How many per day?
Are you interested in advice on how to quit?
Yes
No
How many did you smoke per day?
When did you stop?
Please state how much exercise and what type of exercise you do per week:
Do you have access to secure housing?
Yes
No
If not, are you?
Rough sleeping
Staying with friends
Sofa surfing
Staying in a hostel
Squatting
In a night shelter
Adult Females only
When was the date of your last cervical smear?
Day
Month
Year
Was it done at?
A previous GP
A family planning clinic
What was the result of the cervical smear?
Please write below if you have any further comments about the cervical smear test
Have you had a hysterectomy?
Yes
No
What type of hysterectomy?
Do you still have your ovaries?
Yes
No
Please give names and dates of birth of any children
Alcohol consumption - How many units of alcohol do you consume in a week?
Approximately - 1 drink = 1/2 pint of beer or 1 glass of wine or 1 single spirits. 1 unit of alcohol = 10cc of alcohol. So, a small glass (125cc) of 12% wine is 12.5 * 0.12 = 1.5 units. Find out more about alcohol units on the NHS website
How often do you have a drink containing alcohol?(Required)
Never
Monthly or less
2 to 4 times per month
2 to 3 times / week
4+ times / week
How many units of alcohol do you drink on a typical day when you are drinking?(Required)
None
1 - 2
3 - 4
5 - 6
7 - 9
10+
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?(Required)
Never
Less than monthly
Monthly
Weekly
Daily or almost daily
Family history
Do you have any significant family history we should be aware of?
Medical history
Major illnesses
Please list any major illnesses include dates they occurred
Past operations
Please list details of any operations and dates
Family history illnesses
Please list the illnesses and dates these occurred
Current medication
Please list any current medication you have been prescribed
Sight
Good
Poor
Registered blind
Hearing
Good
Poor
Partially deaf
Deaf
Students
I am less than 24 years old and have had two doses of the MMR Vaccination
Yes
No
Unsure
I am less than 25 years old and have had a Meningitis C Vaccination
Yes
No
Unsure
Over 75 years old?
The Department of Health has advised that all patients of 75years and older have a named and accountable GP to oversee their care. Please ask the name of the GP assigned to oversee your care. Please note this does not prevent you from seeing the GP of your choice.
Allergies
Do you have any allergies?(Required)
Yes
No
Allergy details
Immunisation history
Please list any immunisations or vaccinations you have had
Summary Care Record
Do you consent to having a Summary Care Record?(Required)
Read more patient information on SCR
Yes
No
What happens to my information?
I certify that the information I have provided is correct and consent to my personal and medical information being used as stated above.
Signature(Required)
Please type your name to sign this form
Today's date(Required)
Day
Month
Year
Not for urgent medical help(Required)
Yes, I understand this form is NOT for urgent medical help
Consent(Required)
By submitting your details you are consenting to providing this information for improving our services to you. The data you supply on this form will be securely stored on our website, which is hosted by a third party. We will retain this information on the website for no longer than 7 calendar days. Your contact details will not be sold or shared with a third party. I understand I can revoke this consent at anytime by contacting the practice. Our privacy policy can be viewed on this website.
I agree to the privacy policy.
Comments
This field is for validation purposes and should be left unchanged.
You will have a named, accountable doctor who is responsible for coordinating your care. You can still talk to or make appointments to see any of our doctors or nurses, not just your named GP.

We recommend that new patients undertake a health check with a practice nurse.

Your registration will usually be responded to within 2 working days.

Temporary patients

If you are not registered with the surgery you will be unable to see one of our doctors unless you have a serious emergency. In most other cases, calling 111 is a better option.

If you are not registered but need treatment at the surgery you will need to complete a temporary registration form.

You can be registered as a temporary patient for up to three months. This means you can be registered with our practice and remain a patient of your permanent GP. After three months you will have to re-register as a temporary patient or permanently register with our practice.

Click here for further information on the NHS website

Non-English speakers

For help with health information in other languages, please go to the NHS website.

New Patient Registration Combined Form v1.001

Patient's details

Register as a New Patient

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

If you are from abroad

If you are returning from abroad

Supplementary questions

Not ordinarily resident in the UK

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

Demographics

Communication needs

Disability

Were you ever registered with an Armed Forces GP

Immigration status

Carers

Emergency contact

Your health

Adult Females only

Alcohol consumption - How many units of alcohol do you consume in a week?

Family history

Medical history

Students

Over 75 years old?

Allergies

Immunisation history

Summary Care Record

What happens to my information?

Temporary patients

Non-English speakers

Helpful links

Further Info