New patient registration

You can now register as a patient using our online services. Simply complete our new patient registration form below.

Please be aware that you will need to upload valid photographic ID to complete this registration.

Title

Mrs

Miss

Surname

First names

Previous Surname/s

Date of Birth

Checkbox Field

Male

Female

NHS Number

Town and Country of birth

Address

Street Address

Address Line 2

City

County / State

ZIP / Postal Code

Country

Telephone Number

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

Your previous address in the UK

Street Address

Address Line 2

City

County / State

ZIP / Postal Code

Country

Name of previous GP practice while at that address

Address of previous GP practice

Are you from abroad?

Yes

Your first UK address where registered with a GP

Street Address

Address Line 2

City

County / State

ZIP / Postal Code

Country

If previously resident in UK date of leaving

Date you first came to live in UK

Were you ever registered with an Armed Forces GP

Yes

Please indicate if you have served in the UK Armed Forces and/or been registered with a Ministry of Defence GP in the UK or overseas

Regular

Reservist

Veteran

Family Member (Spouse, Civil Partner, Service Child)

Address before enlisting:

Street Address

Address Line 2

City

County / State

ZIP / Postal Code

Country

Service or Personnel number:

Enlistment date:

Discharge date:

Footnote: 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.

If you need your doctor to dispense medicines and appliances*

I live more than 1.6km in a straight line from the nearest chemist

I would have serious difficulty in getting them from a chemist

*Not all doctors are authorised to dispense medicines

If you are applying on behalf of a child who is in foster care/residential care/Kinship care/ or who is not your child

Who has the legal responsibility for the child?

You as the legal parent/guardian/foster carer

N/A

OtherOther

If other is selected please supply the Name and Contact Number

If you are the parent/guardian/foster carer but cannot consent please detail below who can

N/A

Give details

If you are the parent/guardian/foster carer but cannot consent please detail below who can

Are you an Adult with social care involvement?

Yes

Please state the reason why

Data Sharing

Summary Care Record (SCR)

Tick this box if you wish to opt-in to the SCR 2.1

Tick this box if you wish to opt-out of the SCR

The SCR is a summary of your medical history that can be shared between healthcare staff treating patients in an emergency or out-of-hours with faster access to key clinical information. More information can be found by visiting www.nhscarerecords.nhs.uk

Do you consent to receive the following types of communication from us?

Mobile phone text messages

Answering machine messages

Please tick for Yes and Leave blank for no.

Do you have a Carer?

Yes

What is their name and contact number?

Are you a Carer?

Yes

Do you look after someone who is a patient of our Practice?

Yes

What is their name?

Are they a:

Relative

Friend

Neighbour

Name of next of kin

Relationship to you

Next of kin telephone number(s)

Next of kin address

Do you have any current health problems, please include dates? (i.e Asthma, diabetes, etc)

Are you taking warfarin? Please provide last 5 readings/dosage changes, and/or a copy of your yellow book.

Do you have any allergies?

Yes

Please specify

How many units of alcohol do you consume a week?

What are your smoking habits?

Smoker

Ex-Smoker

Never Smoked

How many do you smoke a day?

Rutland Stop Smoking Service: 01572 725805 www.rutlandrap.org.uk

If a child, are they looked after?

Yes

N/A

Under what arrangements:

Section 20-Voluntary Care

Special Guardianship order

Interim Care Order

Care Order

Private Fostering

If a child, are they living in a Private Fostering arrangement? (please note you have a duty to notify social care of this arrangement) What is Private Fostering? A private fostering arrangement is one that is made without the involvement of the Local Authority to look after a child under the age of 16 (or under 18 if disabled) by someone other than a parent or close relative, for 28 days or more and can include those living with extended family members. So, this could be a child living with people as stated below:

Private Fostering includes a child living with:

• godparents
• great-grandparents
• great aunts or uncles
• family friends
• step parents where a couple isn't married or in a civil partnership
• cousins
• a host family which is caring for a child from overseas while they are in education here

Private Fostering does not include a child living with:
• brothers
• sisters
• grandparents
• aunts
• uncles
• step parents where a couple is married or in a civil partnership
• mother
• father
• children and young people who are being looked-after by the Local Authority

Please specify:

English/Welsh/Scottish

Northern Irish

Third ChoiceIrish

Please specify:

Caribbean

African

OtherOther

Please specify:

Indian

Pakistani

Chinese

Please specify:

White + Black Caribbean

White + African

White + Asian

Main spoken languages:

English

OtherOther

Interpreter required?

Yes

Height

(m,cm)

Weight

(kg)

Please nominate a pharmacy:

Yes

So we can send your prescription direct to them

Pharmacy Details

Please enter your nominated pharmacy details

Domestic Abuse:

Domestic Abuse

If domestic abuse is affecting your health you can speak to someone here. Please tick this box if you would like a GP to contact you.

Please record any additional information about you that you think is important for us to know

(Additional information includes: Social worker involved with your family; legal parental responsibilities of minor under 16 years old; applicant is in foster care or is adopted; if you are from overseas and claiming asylum or are a refugee)

Signature

Date

Signed On Behalf Of (if applicable)

(Minors under 16 years old, adults lacking capacity)

Relationship To Patient

Please upload your ID

Maximum upload size: 2.1MB

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