Online Registration for Park Medical Practice

Please fill in your details and click Submit when complete. * = compulsory

Please only complete this registration form once. If you have previously submitted this
form at any time please do not do so again unless advised to by the practice.
Please do not use this form to update your address or other details.

* Title:       
 If you don't know your NHS number it's very important that you fill in part 1 and 2 below
Find my NHS number
* Gender:
* To be completed by University Students only living in halls of residence.
All other patients, please type in your new address below.
Please include block and flat number if applicable!

Enter your own telephone number. Preferably your mobile number

Enter your e-mail address
Confirm your e-mail address
* What is your preferred contact method?      
Do you give explicit consent for us to contact you via text message or email?
* Have you ever worked in the Armed Forces (regular or reserve)?
* Are you married to/or a dependant of a veteran or a current member of the Armed Forces?
Please help us trace your medical records by selecting if you are a UK or International
patient (Part 1) and then filling in the next section (Part 2)
* Part 1. Select if you are from UK or abroad:
Part 2: Fill in if you come from the UK
Previous address in UK before going to University

* Approximate date of first living at this address: Date you first lived at this address

Part 2: Fill in if you come from abroad (international patient)
Date you think you will leave UK

Date you left UK if you had registered with a GP before
Supplementary Questions:
Please select one of the following options: More information...
Complete the following section if you come from another EEA country:
Do not complete this section if you have an EHIC issued by the UK.
Do you have a non-UK EHIC or PRC?   

(e.g. if you are retiring to the UK or you have been posted here by your employer for work or you live in the UK but work in another EEA member state). Please give your S1 form to the practice staff. More information...
* Signature:
Please draw your unique signature in the box
Health Questionnaire
Are you a CARER for someone?
Prescriptions will be sent to your nominated pharmacy electronically, please select one of the following:
      Find your pharmacy name and postcode
* Do you smoke?
Would you like assistance to quit smoking? Please contact: or call 01332 641254
(to be completed by patients aged 13+)
Not sure of your alcohol consumption?  
 cm  kg
* Patient Access Online
I would like to be able to book/cancel/manage appointments, update my contact details and order repeat
prescriptions online:(if you select yes, your user details and unique pin will be emailed to you once your
medical registration has been fully processed by the health authority – this may take a few weeks)
* Summary Care Records (SCR)
Summary Care Record (SCR) - this is an electronic record which contains information about the medicines you take,
allergies you suffer from and any bad reactions to medicines you have had. Having this information stored in one place
makes it easier for healthcare staff to treat you in an emergency, or when your GP practice is closed.
* Sharing Additional Information within the Summary Care Record (SCR)
It is practice policy to share information that is recorded on your clinical record with other clinical staff
that you are under the care of to ensure the best care is provided to you. For further information
please ask for an information leaflet or visit this site.
Additional information includes reason for medication, significant medical history, significant procedures,
anticipatory care information, communication preferences, end of life care, immunisations.
For further information visit this site.
Do you need any SPECIAL REQUIREMENTS when attending appointments
(please tick) or please advise of any other:
Next of Kin
Who you would like us to contact in the event of an emergency?
To be completed for patients aged UNDER 16
Who has Parental Responsibility?
Is the patient under the care of Social Services?     
Please attach a copy of the child's Birth Certificate:
Organ Donor Registration
The law has changed so that you need to opt out if you do not want to become a donor. It’s
important to talk to your family about your organ donation decision, as they will be asked to
support your decision. If you are undecided or do not want to become an organ donor, please
refer to the NHS Organ Donation website at or 0300 123 23 23.
Blood Donor Registration
If you are interested in becoming an blood donor, please click this link
to go to the blood donor registration page.
Please read our Privacy Notice.
The information you are submitting will be sent encrypted to the medical practice over the Internet, which still isn't 100% secure.
If you are worried about this you can instead obtain a form from the medical practice that can be filled in and delivered by hand.
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