Register Online

Patient Details

Layout

Title

Surname

Name

First

Last

Layout

Date Of Birth

Do you have a NHS Number?

Yes
No

Sex

Address

Town & Country of Birth

Home address

Postcode

Email

City

Home Telephone

Mobile

Layout

Tracing your medical records

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

Address

Name of previous doctor while at that address

If you are UK resident please specify your previous GP name here!

Name of previous practice

Previous Doctor address

If previously resident in UK, date of leaving

Date you first came to live in UK

Mandatory field if you have not provided a NHS number.

Your care connected

Can we share your GP record with other health and social care providers? (for example, GP practice to practice sharing for extended opening hours and seven day access).

Yes
No

Summary care records

Would you like your clinical information to be withheld from the summary care record? (If you Opt-Out, the NHS health care staff caring for you may not be aware of your current medications, allergies you suffer from and any bad reactions to medicines you have had, in order to treat you safely in an emergency).

Yes
No

Please choose the best option that describes your ethnic group or background from the dropdown below:

Layout

White

Any other white backgroud (Please write in)

Asian or Asian British

Any other backgroud (Please write in)

Other ethic group

Chinese
Filipino

Mixed

Any other mixed backgroud (Please write in)

Black or Black British

Any other backgroud (Please write in)

Not stated

Not stated should be used where the PERSON has been given the opportunity to state their ETHNIC CATEGORY but choose not to.

If you are returning from the Armed Forces

Previous Doctor address

Enlisting Address

Service or Personnel number

Postcode

Enlisting date

Do you have a Nominated Pharmacy?

Yes
No

Layout

Tuberculosis Questionnaire

Are you aged between 16 & 35 years old?

Yes
No

Were you born in, or have spent more than 6 months living in one of the countries listed below in last 5 years?

Yes
No

Please select the country from the list!

Please select the country from dropdown listed above!

Did you enter the UK within the last 5 years?

Yes
No

Name of the country where you spent more than 6 months in the last 5 years, if it is not listed in previous question?

If you are registering a child under 5

If you are registering a child under 5!

I wish the child above to be registered with the doctor named overleaf for Child Health Surveillance

If you need your doctor to dispense medicines and appliances

If you need your doctor to dispense medicines and appliances!

I live more than 1 mile in a straight line from the nearest chemist
I would have serious difficulty in getting them from a chemist

Patient Signature

Patient Signature!

I confirm registration I am the patient above
I confirm registration on behalf of the patient above

Upload your ID & proof of address

Click or drag files to this area to upload. You can upload up to 3 files.

NHS Organ Donor Registration

I want to register my details on the NHS Organ Donor Register as someone whose organs/tissue may be used for transplantation after my death. Please tick the boxes that apply

NHS Blood Donor Registration

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

Tick here if you have given blood in the last 3 years
I confirm consent to inclusion on the NHS Blood Register

Updating preview…

Day	Opening hours
Monday	8am to 08:00pm
Tuesday	8am to 08:00pm
Wednesday	8am to 08:00pm
Thursday	8am to 08:00pm
Friday	8am to 08:00pm
Saturday	9am to 5:00pm
Sunday	Closed

Phone

Email

Emergency

Non Emergency

Patient Details

Tracing your medical records

Your care connected

Summary care records

If you are returning from the Armed Forces

Tuberculosis Questionnaire

If you are registering a child under 5

If you need your doctor to dispense medicines and appliances

Patient Signature

NHS Organ Donor Registration

NHS Blood Donor Registration

Opening times

Quick Links

Subscribe our newsletter