New Patient Registration Form & Health Questionnaire: (5 years & older)

Non-urgent advice: As part of your registration to this practice, you will need to set up an online Anima account

Follow the instructions on our homepage on how to set up an Anima account.

Please ring reception if you are experiencing any difficulties with setting up your online Anima account.

Completing a registration form

A relative or friend can complete the form with your consent.
Once you have completed all the necessary documentation, your registration will be processed by our administrative team. Your medical records will be transferred to us from your previous doctor.
If you have not had a doctor in the UK before, a unique National Health Service (NHS) Number will be provided by the NHS (not by your GP surgery).

How long does it take to register as a new patient at the surgery?

Once we have received your fully completed and signed registration form with health questionnaire, it can take up to 10 working days for us to register you at the surgery. Delays can occur when we don’t receive all the information required in support of your registration application.

Helpful Links for new patients

Here are some links you might find useful in helping with your registration application:

Out of Area Patients
Temporary Residents
Supporting the Homeless
Military Veterans
Gender Recognition Certificates
Patient Participation Group
Friends & Family Test

Proof of identification

Forms of identification

– 1 x photo ID (e.g. Passport / Driving License Photo ID. / employment ID)

– 1 of the following for proof of your address (Dated within the last 3 months) Utility bill, council tax bill / statement, bank statement, building society statement or a telephone bill

– Your NHS number. This can be found on the NHS app, hospital/GP documents/in the red book for a child’s number.

Do you have these forms of identification?

Yes

Please upload 2 forms of identification

Drop files here or

Max. file size: 50 MB.

Please contact us/call into the surgery if you do not have 2 forms of identification so we can help you with your application. Our Receptionists will be able to advise you about this.

Your Details

Name

Title First Last

Do you have a previous surname?

Yes

Previous Name

Surname

NHS number

If you have an NHS number you must provide this.

Date of Birth

Day

Month

Year

Contact number

Mobile number

Enter Email Confirm Email

Address

Street Address Address Line 2 City Postcode

Gender

Male

Female

Please visit ‘Apply for a Gender Recognition Certificate (www.gov.uk)’ for information on gender.

Town and Country of Birth

Occupation

OK to receive SMS text alerts from us?

Yes

Name of Nominated Pharmacy

Pharmacy address

Street Address Address Line 2 City Postcode

What is your Ethnicity?

Please specify

Preferred language

Is an interpreter required?

Yes

Which language is required?

Medical Records

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

Have you previously lived in the UK?

Yes

Your previous address in UK

Street Address Address Line 2 City Postcode

Name of previous GP practice

Address of previous GP practice

Street Address Optional Address Line 2 Optional City Optional Postcode Optional

Your first UK address where registered with a GP

Street Address Optional Address Line 2 Optional City Optional Postcode Optional

Date you first came to live in the UK:

Day

Month

Year

Blood Donor Register

NHS Blood Donor registration I would like to join the NHS Blood Donor Register as someone who may be contacted and would be prepared to donate blood.

Have you given blood in the last 3 years?

I have given blood in the last 3 years

I have not given blood in the last 3 years

Joining the NHS Blood Donor Register

I confirm my consent to join the NHS Blood Donor Register Optional

All blood types are needed, especially O negative and B negative. Visit www.blood.co.uk or call 0300 123 23 23.

Health Questionnaire

Smoking

Never smoked

Current smoker

Ex-smoker

I vape using an e-cigarette

How many of the following do you smoke;

Cigarettes per day

Cigars per day

Ounces of tobacco per day

How often do you vape?

How old were you when you stopped smoking?

How often did you smoke per day?

Alcohol

1 unit = half pint of beer, 1 glass of wine, or 1 pub measure of spirits

How many units of alcohol do you drink per week?

Family History

Is there any of the following within your family (e.g. father, mother, brother, sister) before the age of 60?

Heart Disease (Heart attacks, angina)

Stroke

Breast cancer

None of the above

Please state which family member has these conditions

Height & Weight

What is your current weight?

(kg / lbs)

What is your height?

(cm / ft/in)

Carer Status & Next of Kin

Are you housebound?

Yes

Do you have a carer?

Yes

Name of person who cares for you

Do you care for someone else?

Yes

Name of person you care for

Do you have lasting power of attorney for a next of kin?

Yes

Please provide supporting evidence or documentation

Drop files here or

Max. file size: 50 MB.

Name

First Last

Would you like them to deal with your health affairs here?

Yes

Next of kin name

First Last

Relationship to patient

Next of kin contact number

Next of kin Email

Enter Email Confirm Email

Permissions

Do you give your permission for someone else to collect items on your behalf?

Yes

I give permission for the below person(s) to collect any of the items listed on my behalf:

Prescriptions

Letters

Medical Forms

Blood test Forms

1. Name

First Last

1. Contact Number

1. Relationship to me

Do you wish to give your permission to another person to collect items on your behalf?

Yes

2. Name

First Last

2. Contact Number

2. Relationship to me

Do you give your permission to someone else to access your medical information?

Yes

I give my permission to the following person(s) to access my medical information

1. Name

First Last

1. Relationship

Do you wish to give your permission to another person to access your medical information?

Yes

2. Name

First Last

2. Relationship

Armed Forces Veterans

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

UK or Overseas

Regular

Reservist

Veteran

Family Member

None of the above

Date of Enlistment

Day

Month

Year

Discharge date

Day

Month

Year

Service or Personnel Number

Confirmation

I understand and agree with all the above statements in this form.

Patient’s signature

Signature on behalf of the patient Optional

Date

Day

Month

Year