Online Registration

Please fill in your details and click Submit when complete.

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 by the Medical Centre to do so.
Please do not use this form to update your address or other details.

Have you ever registered
with this practice before?
* Title:
Please enter your surname or family name
Please enter your first name
  If you don't know your NHS number it's very important that you fill in part 1 and 2 below  
* Gender:   
* Is this your gender from birth?
Please select your new home ADDRESS from the list OR fill it in below:
Student Accommodation:
If you don't have a HD postcode, please contact the practice before completing this registration form.
Enter your own telephone number. Preferably your mobile number
A confirmation message will be sent to this address.
Confirm your email address
* May we contact you using email?    
* May we contact you using SMS text?    
* What is your preferred contact method?    
Enter a person (full name including surname) we should contact in case of an emergency
Enter a phone number to the emergency contact
Enter your relationship to the emergency contact
Have you previously been   
registered with the Forces?
Please help us trace your medical records by selecting if you are from UK or from
abroad (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
(i.e. last address before moving here)

Part 2: Fill in if you come from abroad
You can't register before you arrive in the UK
Have you lived or studied in the UK 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
* Ethnic origin:  
Need interpreter:     
* *
 cm  kg
Your Body Mass Index (BMI) is:
Please contact the practice for advice if your BMI is over 30.
Physical Activities and Eating Habits:
* Do you exercise?   
Are you a carer?     Do you have a carer?  
* Please tick if you have, or have had, any of the following ILLNESSES or none:
Has anyone in your immediate family suffered from...
* Do you SMOKE?

  NHS Alcohol Unit Calculator
How often do you have a drink that contains ALCOHOL?
How many standard alcoholic drinks do you have on a typical day when you are drinking?
How often do you have 6 or more standard drinks on one occasion?
* Do you use recreational DRUGS?   
Do you have a Disability or Special Communication Needs?     
Please provide your preferred means of communication:
* Please note not all information is currently readily available *
Please indicate if you've had any of the following immunisations, and when:
MMR1:      MMR is
given when
a child.
Meningitis ACWY:         
* 1st COVID-19 dose:     
* 2nd COVID-19 dose:     
People with a cervix over the age of 25
Have you ever had a smear test?    
If you are over 25 and have not yet had a smear please make an appointment with the Practice Nurse.
Have you had HPV VACCINATION?    
* NHS Records
There are strict laws and regulations to ensure that your health records are kept confidential and can only be accessed by health professionals directly involved in your care. There is some sharing of information as detailed below. You can opt out of any of these at any time if you wish.
NHS 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.
General Data Protection Regulations
I hereby give consent under the new General Data Protection Regulations 2018 for:
You have the right to withdraw your consent at any time. It is the responsibility of the patient to inform the
practice of any change of personal data under the new General Data Protection Regulations 2018.
Online services of all types are vulnerable to coercion. In the context of Patient Online,
coercion might result in patients being forced into sharing information from
their medical record, including login details, medical history, repeat prescription
orders, GP appointment booking details and other private, personal information.
* Would someone else ask for your access to your medical
information if you were given online access?
We are able to offer full access to your medical records. If you are interested in this service
please speak to the reception staff or visit our website for more information.
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.
* = Compulsory.
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