Patient Registration

To access our services, you will need to be registered as a patient with us.

The registration process is quick and easy. Fill out the form and our admin team will process your registration.

If you are interestied in registering, please check that you are within the catchment area of the practice.

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

  • Patient Details
  • Previous information
  • Additional info
  • Communication
  • Patient Declaration

Patient Details

Title

Surname

First Name(s)

Date of Birth

Previous Surname(s)

NHS Number (if known)

Gender

Postcode

Address

Email

Contact Number

Alternative Number

Ethnicity

Religion

Main or 1st language spoken/understood

Proof of address - Please provide a copy of a document, not older than 3 months, that provides a proof of address.

Previous details in UK

Your previous address & postcode in UK

Name of previous GP

Address of previous GP practice

If you are from abroad

Your first UK address where registered with a GP

If previously a resident in UK, date of leaving

Date you first came to live in UK

Were you ever registered with an Armed Forces GP

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:

Address & postcode before enlisting

Service or Personnel number:

Enlistment date

Discharge date (if applicable)

Footnote: These questions are optional and your answers will not affect your entitlement to register or receive services from the NHS but may improve access to some NHS priority and service charities services.

Donor Registration

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.

Please tell your family you want to be an organ donor. If you do not want to be an organ donor, please visit www.organdonation.nhs.uk or call 0300 123 23 23 to register your decision.

NHS Blood Donor registration

Carer Information (not needed for children)

Do you have a Carer?

If yes, are they registered at this practice?

Carer name:

Telephone number:

Do you consent for your carer to be informed about your medical care?

Are you a Carer? (Only if you are a registered Carer)

If yes, do you look after someone who is a patient at this practice

If yes, what is their name?

Are they a

Please upload a photo ID

Please tell us about your smoking habits, alcohol consumption, and exercises (not needed for children)

Do you smoke?

If yes, how many do you smoke a day?

Would you like advice on quitting?

Are you an ex-smoker?

Do you drink alcohol?

If yes, How much alcohol do you drink in a week (Units)?

Do you exercise?

If yes, How often do you exercise? (No. times per week and type(s) of exercise)

Medical Background

Have you had a Cervical Smear

Please state where, when and the result

Please ask the surgery to fill in a disclaimer form.

What illnesses have you had and when? (Existing long term conditions)

Please list any tablets, medicines or other treatments you are currently taking: (including dose and frequency)

Are there any serious disease that affect your parents, brothers or sisters ( tick all that apply)

Any other important family illness?

Please detail below any specific needs you have so that practice can ensure they are identified and accommodated by taking the appropriate action.

Are you allergic to any medicines?

If yes, please specify

Do you have any other allergies?

List any other allergies you have (pollen, animal hair or certain foods)

Please select any Sensory Impairment you have.

Are you an Assistance Dog user?

Please state any physical disabilities you have.

Please state any mental disabilities you have.

Please state any requirements you have to be able to access the practice premises.

Communication needs

We would like to get better at communicating with our patients. We want to make sure that you can read and understand the information we send you. If you find it hard to read our letters or if you need someone to support you at appointments, please let us know. We want to know if you need information in braille, large print or easy read. We want to know if you need an interpreter for your appointments.

Do you have any communication needs?

What type of communication needs?

Do you need a format other than standard print?

Do you have any special communication requirements?

Spoken language

English speaker

Spoken Language:

Interpreter needed:

If yes what language

Electronic Prescribing

We have electronic prescribing functionality, this will allow us to send your prescription electronically to your preferred choice of pharmacy, and will also save you time in collecting your prescription from the surgery.

Please give the name and address of your preferred pharmacy :

Alternatively, you can collect it from the surgery

Consent

Your Care Connected
This practice is part of Your Care Connected (YCC), a potentially lifesaving local NHS record sharing service, implemented across Birmingham, Sandwell and Solihull to provide better, safer care. If you need to attend a local hospital, YCC makes it possible for the authorised health and care staff, who are caring for you, to securely access important medical information from your GP record to provide you with better, safer care. To learn more about YCC, visit the Your Care Connected website. If you are happy to take part, you do not need to do anything. If you visit one of the participating organisations, those treating you will be able to securely access vital information from your record to help improve the care you receive. If you do not want your information shared, you will need to opt out. To opt out, please complete an opt out form. Your practice will then process your request to not share your record.

Summary Care Record
If you are registered with a GP practice in England, you will already have a Summary Care Record (SCR), unless you have previously chosen not to have one. It will contain key information about the medicines you are taking, allergies you suffer from and any adverse reactions to medicines you have had in the past. Click here for more information. If you wish to opt out, please complete an opt out form.

This practice uses a text messaging service to remind patients of appointments and remind patients when they are due for a review. If you provide a mobile number when registering, you will automatically be opted in to receive text messages. If you wish to opt out, please click the checkbox.

Please select one or more preferred method of contact

I declare that the information provided on this form is correct to the best of my knowledge

I consent to being contacted via the details given above. I agree to the privacy policy

To view our privacy policy, click here