Pre-registration Form


    Fields marked with a red asterisk 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

    Please note that by using this form you will be sending information about yourself across the Internet. Whilst every effort is made to keep this information secure, you should be aware that we cannot offer any guarantees of absolute privacy. If this matter concerns you then you should use another method of registration.

    Patient's Details - Please complete the text boxes and tick where appropriate

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

    If you are from abroad

    If previously resident in UK, date of leaving

    If you are returning from the armed forces


    Service/Personnel No.

    Enlistment date

    If you are registering a child under 5
    I wish the child above to be registered with the named doctor for Child Health Surveillance

    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

    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:
    Any of my organs and tissue or
    Kidneys Heart Liver Corneas Lungs Pancreas Any part of my body

    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.

    Supplementary questions

    PATIENT DECLARATION for all patients who are not ordinarily resident in the UK
    Anybody in England can register with a GP practice and receive free medical care from that practice.

    However, if you are not 'ordinarily resident' in the UK you may have to pay for NHS treatment outside of the GP practice. Being ordinarily resident broadly means living lawfully in the UK on a properly settled basis for the time being. In most cases, nationals of countries outside the European Economic Area must also have the status of 'indefinite leave to remain' in the UK.

    Some services, such as diagnostic tests of suspected infectious diseases and any treatment of those diseases are free of charge to all people, while some groups who are not ordinarily resident here are exempt from all treatment charges.

    More information on ordinary residence, exemptions and paying for NHS services can be found in the Visitor and Migrant patient leaflet, available from your GP practice.

    You may be asked to provide proof of entitlement in order to receive free NHS treatment outside of the GP practice, otherwise you may be charged for your treatment. Even if you have to pay for a service, you will always be provided with any immediately necessary or urgent treatment, regardless of advance payment.

    The information you give on this form will be used to assist in identifying your chargeable status, and may be shared, including with NHS secondary care organisations (e.g. hospitals) and NHS Digital, for the purposes of validation, invoicing and cost recovery. You may be contacted on behalf of the NHS to confirm any details you have provided.

    Please tick one of the following boxes:

    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.

    NON-UK EUROPEAN HEALTH INSURANCE CARD (EHIC), PROVISIONAL REPLACEMENT CERTIFICATE (PRC) DETAILS and S1 FORMS

    If you are visiting from another EEA country and do not hold a current EHIC (or Provisional Replacement Certificate (PRC)/S1, you may be billed for the cost of any treatment received outside the GP practice, including at hospital).

    [recaptcha]