New Patient Registration Form (GMS1) 2022

Fields marked '*' are compulsory. You should only send this form if you are sure that you are eligible to join this practice. Sending this form will NOT automatically register you with the surgery. Your details will be held at the surgery for a limited period of time. You are required to present in person to sign your registration form and provide proof of your address. Sending this form does NOT guarantee or even imply that you will be accepted onto the practice register.

Last Updated: 06/03/2024

Patient's Details

Next of Kin

Relationship to you

Title

First name(s)

Surname

Sex

Male

Female

Telephone

Contact information

Telephone *

DO YOU CONSENT TO RECEIVING OCCASIONAL SMS MESSAGES FROM THE PRACTICE, REGARDING YOUR HEALTH AND APPOINTMENT REMINDERS? *

Yes No

Email *

DO YOU CONSENT TO RECEIVING OCCASIONAL EMAILS FROM THE PRACTICE WITH PRACTICE NEWS, EMAILS REGARDING YOUR HEALTH AND APPOINTMENT REMINDERS? *

Yes No

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

Name and address of previous GP practice

If you are from abroad

Your first UK address where registered with a GP

If previously resident in UK, date of leaving

Date you first came to live in UK

What is your country of birth and ethnic group?

Please tick one box that best describes your ethnic group or background from the options below:

Housing and Empolyment

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 services.

NON-UK EUROPEAN HEALTH INSURANCE CARD (EHIC)

Complete this section if you live in another EEA country, or have moved to the UK to study or retire, or if you live in the UK but work in another EEA member state. Do not complete this section if you have an EHIC issued by the UK. If you are visiting from another EEA country and do not hold a current EHIC, you may be billed for the cost of any treatment received outside the GP practice, including at hospital).

Do you have a non-UK EHIC?

Yes No

Were you or are your family part of the Armed Forces

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.

Please indicate if you or your family have served in the UK Armed Forces

I am a military Veteran

I am part of a military family

Discharge date (if applicable)

Communication needs

What is your main spoken language *

Do you require an interpreter *

Yes No

Carer / Cared for

Are you cared for by someone

I have a carer (their occupation is a carer)

I have an informal carer (family/friend/neighbour)

Are you a carer (this is your occupation)

Yes No

Are you an informal carer (it is not your occupation but you care for someone)

I care for a friend

I care for a neighbour

I care for a relative

I care for someone other than the options above

Family Medical History

Your Medical History

Please provide below any significant medical history regarding yourself (major operations, disabilities etc)

Please list any allergies you have

Please list any prescription medications you are currently taking and the doses for each

Lifestyle Questions

Physical observations

Recent blood pressure (if known)

Height *

Weight *

WOMEN ONLY

Contraception

Currently on contraception

Contraception not needed

If you selected 'Contraception not needed' please explain why below (not sexually active, had hysterectomy etc)

Are you currently pregnant

Yes

Possibly

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New Patient Registration Form (GMS1) 2022

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