New Patient Registration

If you would like to register with the practice please use this form.

Patients wishing to register with the practice may do so if their address is within the practice catchment area. Practice policy is to register complete households only. Please check our boundary map and if you are in any doubt, please telephone the practice to confirm.

Catchment Area

• Barton
• Clophill
• Flitton
• Greenfield
• Gravenhurst (Upper and Lower)
• Harlington
• Hexton (Hertfordshire)
• Higham Gobian
• Maulden (only part)
• Pegsdon
• Pulloxhill
• Sharpenhoe
• Shillington
• Silsoe
• Streatley

New Patient Registration

If you are human, leave this field blank.

Patient's Details

Title *

Mr

Mrs

Miss

Ms

Other

Please specify:

Surname: *

Previous Surnames:

First Name(s) *

Date of Birth: *

Please use this date format: DD/MM/YYYY.

Gender *

Male

Female

NHS Number:

Home Address: *

Postcode: *

Town and Country of birth: *

Home Phone Number:

Mobile Phone Number:

Work Phone Number:

Email Address: *

Please tick the box which best describes your cultural and ethnic origin:

White British

White and Black Caribbean

British or Mixed British

White or Black African

Irish

White or Black Asian

Indian

Other black background

Pakistani

Other ethnic group

Bangladeshi

Other mixed background

Chinese

Other white background

Caribbean

Other Asian

African

Would rather not say

Please specify:

Can we contact you by text?

Yes

No

Can we contact you by email?

Yes

No

Emergency Contact

Full Name:

Relationship to you:

Phone Number:

Are they your Next of Kin?

Yes

No

I give my consent for the person named above to communicate on my behalf with The Surgery staff about my medical affairs. I understand that this could include past and present blood test results, investigation results, referrals, medication and appointments both at The Surgery and hospitals.
This will remain the case until The Surgery is notified in writing otherwise.

Do you give us permission to discuss your medical records with them?

Yes

No

Medication

Current Medication:

Allergies

Do you have any allergies?

Yes

No

Please specify what you are allergic to, what happens and when you had your first reaction:

Previous Details

Previous address in UK:

Please include postcode.

Name and address of previous GP:

Armed Forces

Were you ever registered with an Armed Forces GP?

Yes

No

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)

If you are from abroad

Registering for the first time in the UK

Date you came to live in the UK:

Please use this date format: DD/MM/YYYY.

If you are returning from abroad

Previously been a resident in the UK

Date you left the UK:

Please use this date format: DD/MM/YYYY.

Date you returned to the UK:

Please use this date format: DD/MM/YYYY.

Carers

Do you have a carer?

Yes

No

Are you a carer for someone?

Yes

No

Name of carer:

Phone Number:

Address:

Do you give us permission to discuss your medical record with your carer?

Yes

No