Online New Patient Registration for Children (under the age of 16 years)
Please kindly take a few minutes to fully complete this form as best you can.
To fully complete the registration process please email to us one proof of photo identification (i.e. passport/UK driving license/national idenfication card/travel document) and one proof of address (i.e. utility bill/telephone bill/credit card bill/tenancy agreement/council tax bill) dated within the last 4 months. Please email the images of your documents (i.e. scanned copies/pictures) in a standard format (i.e. pdf/jpeg) to email@example.com.
If you cannot email to us the above documents please do come in person and we will photocopy your documents and attach them to your file.
PLEASE ALLOW 3-4 WORKING DAYS TO PROCESS YOUR ONLINE REGISTRATION THEN BOOK AN APPOINTMENT IF YOU REQUIRE MEDICATION. IF YOU REQUIRE MEDICATION SOONER PLEASE SPEAK TO RECEPTION.
N.B Please be aware that if you are on highly addictive or controlled medications (i.e. tramadol, diazepam, temazepam etc) that we are unable to prescribe these medications until we have your old medical records, so please liaise with the reception to ensure we have these before booking an appointment. Please also note that we do not prescibe out of accordance with national and local medicines management guidelines.
For Details about the Summary Care Record, HIE (Health Information Exchange) and Care.data please go to the following links:
*Please ensure you complete all the mandatory sections in order to be able to submit and process the application form. All the mandatory sections are starred *
PLEASE NOTE CHILDREN WILL ONLY BE RESGISTERED IF ONE OF THEIR PARENTS/MAIN CARER ALSO IS AT OUR SURGERY.
Please note that if you are outside of the practice map area and are likely to require home visits i.e. housebound/mobility issues, then please register with a practice more local to you.
Please help us to trace your previous medical records by providing the following information
If you are from abroad (please go to the section if this does not apply to you)
About your health
FORM COMPLETION SIGNATURE
Supplementary questions for all patients whom are not ordinarily resident in the UK (please go to the section if this does not apply to you)
Anybody in England can register with a GP practice & receive free medical care from the 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 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 teats 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. 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,
CIDR (Clinical Integrated Digital Record)
Patient Participation Group
Information submitted through secure forms is used only for the purposes of processing your request. We may
be in touch with you in relation to the information submitted.
All Information submitted through secure forms is secured with a private key known only to the GP practice and is
accessed over a secure connection by nominated Practice staff. Our practice has a strict confidentiality policy.
This information is not shared with any third party organisations.
This information is retained for up to 28 days.
Should you have any concerns about sending your personal details using the web,
please use one of the alternative methods offered by our organisation.