New Patient Registration Form

Family Doctor Services Registration (GMS1)

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, it may take up to 2 working days. Please check the catchment area before registering.

Patient Details

 

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

 

If you are from abroad

 

If you are returning from the Armed Forces

 

If you are registering a child under 5

 

If you need your doctor to dispense medicines and appliances*

*Not all doctors are authorised to dispense medicines
 

NHS Organ Donor registration

All adults in England are now considered to have agreed to be an organ donor when they die unless they have recorded a decision not to donate or are in one of the excluded groups. If you do not want to donate your organs then you should register your decision to refuse to donate. Remember to speak to your family and loved ones about your decision. Click here to opt-out of organ donation.
 

NHS Blood Donor registration

 

Screening Questionnaire for Latent Tuberculosis infection

If you answer Yes to all three questions below, please contact your GP Practice to arrange a FREE blood test to check for latent TB.
 

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

 

Communication needs-Spoken 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.
 

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 click here to 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 click here to complete an opt out form.
 

Notifications

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.
 

Patient Declaration

Practice Area:

Please check if you live within our practice area by expanding the map.

 

Guidelines: 

It is very important that this form is filled in accurately or this may mean a delay in receiving your medical records. 

 

PATIENTS DETAILS

Title – Mr Mrs Miss Ms – Tick the appropriate box according to your marital status.

 

Surname – Surname or Family name. Please make sure the spelling given, is the same that appears on your passport, driving licence or home office paper work.

 

Date Of Birth – The date you were born. 

 

First Names – First name or Forename. Please make sure the spelling given, is the same that appears on your passport, driving licence or home office paper work.

 

Previous Surname/s – If you are married please state your maiden name or if you have changed your Surname/Family name at any time please state your previous Surname/Family name.

 

NHS Number – If you know your NHS Number which can be found on a medical card.

 

Male / Female – Please tick the appropriate box.

 

Home Address – Please enter clearly your full postal address. 

 

Post Code – You need to print clearly a full post code.

 

Telephone Number – Please enter as many forms of contacting yourself by phone.

 

Your Previous Address in UK – If you were previously registered with a GP Practice then please write the address you were living at when registered. 

 

Name of previous Doctor while at that address – Please state the Doctors name within the GP Practice where you were registered.

 

Address of previous Doctor – Please state the area where the GP Practice was.

 

IF YOU ARE FROM ABROAD – Your first UK address where registered with a GP,  Date of leaving  and Date you first came to live in UK – 

 

IF YOU ARE RETURNING FROM THE ARMED FORCES

Address before enlisting – Please state the address where you were last registered with a GP practice before enlisting.

 

Service or Personnel number – This can be found on your Discharge Papers.

 

Enlistment Date – This can be found on your Discharge Papers.

 

If you want to be added to the NHS Organ Donor Register, and/or NHS Blood Donor Register, please complete that section.