Patient Registration

We are actively building up our practice and we welcome new patients to our list. For anyone who wants to register, simply complete the online new patient registration form below. Alternatively you can visit the practice to collect the relevant forms. We encourage all people living at the same address to be registered with the same practice for practical purposes.

Please allow two working days to be fully registered at the practice. 

A copy of our practice leaflet detailing the services we offer is available here

Please ensure you read all the information leaflets containing within the registration form before completing your registration.

If you would like to register with the practice please use this form.

To register as a new patient you will need to live within our practice boundary.

We are happy to register patients who are staying in the area for a short period e.g. students and temporary residents.

You will need to call into the practice to complete a Temporary Resident Registration Form before you make an appointment to see a GP or nurse.

Visitors from countries that have a reciprocal health arrangement can be treated on the NHS; if this is not the case a fee for consultation and treatment will be payable.

Step 1 of 17

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• Patient's Details

• Registration For:*
  AdultChild (Aged Between 5 and 16)Child Under 5
• Name*
  MrMrsMissMsDrProf.Rev.Other Title First Name Middle Name(s) Surname
• Previous Surname
• Date of Birth*
  DD slash MM slash YYYY
• Gender*
  Select one...MaleFemaleIndeterminate
• NHS Number
  Find your NHS number
• Town of Birth*
• Country of Birth*
• Current Home Address*
  Address Line 1 Address Line 2 City County Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country
• Email Address*
  Enter Email Confirm Email
• Home Phone Number*
• Mobile Phone Number*
• Work Phone Number
• Can we contact you by text?*
  • Yes
  • No
  Please be aware if you say “NO” you will not receive appointment reminders via text
• Can we contact you by email?*
  • Yes
  • No
• Marital Status:*
  • Single
  • Married
  • Common Law Partnership
  • Divorced
  • Separated
  • Widowed
• Employment Status:*
  • Employed
  • House Husband
  • Housewife
  • Self-Employed
  • Internaltional Student
  • Unemployed
• Occupation*
• Contraception*
  • Uses Contraception
  • Contraception not Needed
• Pregnancy*
  • Currently Pregnant
  • Possibly Pregnant
  • Not Pregnant
• Pregnancy Expected Due Date*
  DD slash MM slash YYYY
• Current School Address*
  School Name Address Line 2 City County Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country

• Please Click Next

• Healthy Family Team

  Hello,

  Welcome to the Stapleford Area.

  The Health Family Team are based at the following address:

  Nottinghamshire Healthcare (NHS foundation Trust)

  Stapleford Care Centre

  Church Street

  Stapleford

  Nottingham

  NG9 8DB

  Please help us by completing the form below. If you would like to see a member of the Healthy Family Team urgently please contact us on 0115 883 55 00.

  Best Wishes

  Healthy Family Team

• Have you already completed this section for all Children under 5 on a previous registration with us?*
  • Yes
  • No
• Number of Children Under 5?*
  1234
• Name of Child 1*
  First Name Surname DOB (dd/mm/yyyy)
• Name of Child 2*
  First Name Surname DOB (dd/mm/yyyy)
• Name of Child 3*
  First Name Surname DOB (dd/mm/yyyy)
• Name of Child 4*
  First Name Surname DOB (dd/mm/yyyy)
• New Address*
  Address Line 1 Address Line 2 City County Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country
• Current School Address*
  School Name Address Line 2 City County Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country
• Previouse Address*
  Address Line 1 Address Line 2 City County Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country
• Address of previous GP practice
  Address Line 1 Address Line 2 City County Postal Code
• First Language:*
• Date*
  DD slash MM slash YYYY

• Ethnicity

• Please specify the ethnic group you consider you belong to:*
  • White British
  • White Irish
  • White and Asian
  • Black Caribbean
  • Black African
  • Black Caribbean and White
  • Black African and White
  • Indian / British Indian
  • Pakistani / British Pakistani
  • Bangladeshi / British Bangladeshi
  • Chinese
  • I do not wish to state
• Do you speak English?*
  • Yes
  • No
• First Language:*
• Do you need an interpreter?*
  • Yes
  • No

• Emergency Contact

• Name*
  MrMrsMissMsDrProf.Rev.Other Title First Name Surname
• Are they your next of kin?*
  • Yes
  • No
• Relationship to you:*
• Home Phone Number*
• Mobile Number:*

• Previous Details

  Please help us trace your previous medical records by providing the following information
• Are you ordinarily a resident in the UK?*
  • Yes
  • No
• Your previous address in UK
  Address Line 1 Address Line 2 City County Postal Code
• Address of previous GP practice
  Address Line 1 Address Line 2 City County Postal Code

• If you are from abroad

• Are you registering with the NHS for the first time in the UK?*
  • Yes
  • No
• Date you first came to live in UK*
  DD slash MM slash YYYY

• If you are returning from abroad

• If you are returning from abroad, have you previously been registered with the NHS in the UK?*
  • Yes
  • No
• Date you left the UK:
  DD slash MM slash YYYY
• Date you returned to the UK:*
  DD slash MM slash YYYY
• Your first UK address where registered with a GP*
  Address Line 1 Address Line 2 City County Postal Code

• Supplementary Questions

• Please select one of the following statements:*
  • I understand that I may need to pay for NHS treatment outside of the GP practice
  • I understand I have a valid exemption from paying for NHS treatment outside of the GP practice. This includes for example, an EHIC, or payment of the Immigration Health Charge (“the Surcharge”), when accompanied by a valid visa. I can provide documents to support this when requested
  • I do not know my chargeable status
• Consent*
  I declare that the information I give on this form is correct and complete. I understand that if it is not correct, appropriate action may be taken against me.
• Print Name:*
• On behalf of:
• Relationship to patient:
• Date*
  DD slash MM slash YYYY

• Non-UK European Health Insurance Card (EHIC), Provisional Replacement Certificate (PRC) Details and S1 Form

  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.
• Do you have a non-UK EHIC or PRC?*
  • Yes
  • No
• Country Code*
• Given Names*
  DrMissMrMrsMsProf.Rev. Title First Name Surname
• Personal identification number*
• Identification number of the institution*
• Identification number of the card*
• Expiry Date*
  DD slash MM slash YYYY
• PRC valid from*
  DD slash MM slash YYYY
• PRC valid to*
  DD slash MM slash YYYY
• Do you have an S1 (e.g. 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).*
  • Yes
  • No
• Please upload your S1 form*
  Max. file size: 128 MB.

• How will your EHIC/PRC/S1 data be used?

  By using your EHIC or PRC for NHS treatment costs your EHIC or PRC data and GP appointment data will be shared with NHS secondary care (hospitals) and NHS Digital solely for the purposes of cost recovery.

  Your clinical data will not be shared in the cost recovery process. Your EHIC, PRC or S1 information will be shared with The Department for Work and Pensions for the purpose of recovering your NHS costs from your home country.

• Carers

• Do you have a carer?*
  • Yes
  • No
• Name of carer:*
  MrMrsMissMsDrProf.Rev.Other Title First Name Surname
• Phone number of carer:*
• What relationship is the person that cares for you?*
• Do you give us permission to discuss your medical record with your carer?*
  • Yes
  • No
• Are you a carer for someone?*
  • Yes
  • No
• What relationship is the person you care for?*

• Were you ever registered with an Armed Forces GP

• Click Next

• Are you returning from the Armed Forces?*
  • Yes
  • No
• Which Branch of the Armed Forces did you serve with?*
  • Military
  • Army
  • Royal Air Force
  • Royal Marines
  • Royal Navy
• 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 Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country
• Service or Personnel number:*
• Enlistment date:*
  DD slash MM slash YYYY
• Discharge date:*
  DD slash MM slash YYYY

• Lifestyle

• Height*
  Please enter a number less than or equal to 3.00.
• Weight*
  Please enter a number less than or equal to 100.
• Please state how much exercise and what type of exercise you do per week:
• e-Cigarette Status:*
  • Current User of e-Cigarettes
  • Ex User of e-Cigarettes
  • No
• Smoking Status:*
  • Current Smoker
  • Ex Smoker
  • Never Smoked
• How many do you smoke per day?*
• Are you interested in advice on how to quit?*
  • Yes
  • No

• Help to Quite Smoking

  Please visit Your Health Notts for information on how to stop smoking. You will also receive a text message with the above link once registered as a patient.
• How many did you smoke per day?*
• When did you stop?*
  DD slash MM slash YYYY
  Estimated Date

• Alcohol Consumption

• Click Next

• This is one unit of alcohol:

• 

• And each one of these, is more than one unit:

• 
• How often do you have a drink containing alcohol?*
  • Never
  • Monthly or less
  • 2-3 times per month
  • 2-4 times per week
  • 4+ times per week
• How many units of alcohol do you drink on a typical day when you are drinking?*
  • 1-2
  • 3-4
  • 5-6
  • 7-9
  • 10+
• How often have you had 6 or more units if female, or 8 or more if male, on a single occasion in the last year?*
  • Never
  • Less than monthly
  • Monthly
  • Weekly
  • Daily or almost daily
• How often during the last year have you found that you were not able to stop drinking once you had started?*
  • Never
  • Less than monthly
  • Monthly
  • Weekly
  • Daily or almost daily
• How often in the last year have you failed to do what was expected of you because of drinking?*
  • Never
  • Less than monthly
  • Monthly
  • Weekly
  • Daily or almost daily
• How often in the last year have you needed an alcoholic drink in the morning to get you going?*
  • Never
  • Less than monthly
  • Monthly
  • Weekly
  • Daily or almost daily
• How often in the last year have you had a feeling of guilt or regret after drinking?*
  • Never
  • Less than monthly
  • Monthly
  • Weekly
  • Daily or almost daily
• How often in the last year have you not been able to remember what happened when drinking the night before?*
  • Never
  • Less than monthly
  • Monthly
  • Weekly
  • Daily or almost daily
• Have you or someone else been injured as a result of your drinking?*
  • No
  • Yes, but not in the last year
  • Yes, during the last year
• Has a relative/friend/health worker been concerned about your drinking or advised you to cut down?*
  • No
  • Yes, but not in the last year
  • Yes, during the last year

• Medical History

• Do you suffer from any of the following?*
  • Asthma
  • Epilepsy
  • Diabetes
  • Stroke
  • Heart attack
  • Heart Problem
  • Cancer
  • Depression
  • Mental Health Illness
  • COPD
  • High Blood Pressure
  • Thyroid
  • Dementia
  • Atrial Fibrillation
  • None
• Any other important illnesses, previous operations or any other significant medical history?
  Please list.
• Sight:*
  • Good
  • Poor
  • Registered Blind
• Hearing:*
  • Good
  • Poor
  • Partially Deaf
  • Deaf
• Do you have any specific communication needs?*
  • Yes
  • No
• Please specific communication needs?*
  • Blind
  • Partially sighted
  • Deaf
  • Hearing Impaired
  • Memory problems
  • Learning disability
  • Autism
  • Other
• If you selected one of the above, how should we contact you? (If you would like us to contact you via another person please provide their details.)

• Allergies

• Do you have any allergies?*
  • Yes
  • No
• Please specify what you are allergic to, what happens and when you had your first reaction:*

• Medication

• Are you on current medication (repeat)?*
  • Yes
  • No
• Please attach a repeat slip for any repeat medications you are currently taking
  Accepted file types: jpg, png, pdf, Max. file size: 128 MB.
• Current Medication:
  Please list If you cannot attach a repeat slip.
• If you would like to nominate a pharmacy to send your prescriptions electronically to please state here:

• Summary Care Record

  NHS England has introduced the Summary Care Record to be used in Emergency care.

  The record will contain information about any medicines you are taking, allergies you suffer from & any bad reactions to medicines you have had to ensure those caring for you have enough information to treat you safely.

  More details concerning the Summary Care Record and what it means to you can be found here.

• Do you consent to the shared NHS Summary Care Record (SCR)?*
  • Yes
  • No

• Summary Care Record Opt Out

  Your Summary Care Record contains important information from the record held by your GP practice and includes details of any medicines you are taking, any allergies you suffer from and any bad reactions to medicines that you have previously experienced.

  Your Summary Care Record also includes your name, address, date of birth and your unique NHS Number to help identify you correctly.

  As part of a mandatory national programme each GP Practice had to make a summary care record for each patient by March 2015 (unless the patient has already opted out).

  You can choose to opt out of this scheme at any time.

  If you wish to opt out of the Summary Care Record scheme please complete the following form.

• Section A

  If you are filling this form on behalf of another person or child please ensure you fill their details in section A and your details in section B.
• Name*
  MrMrsMissMsDrProf.Rev.Other Title First Name Surname
• Address*
  Street Address Address Line 2 City County Postal Code
• Phone Number*
• Email

• Section B

  If you are filling this form on behalf of another person or child please ensure you fill their details in section A and your details in section B.
• Name*
  MrMrsMissMsDrProf.Rev.Other Title First Name Surname
• Relationship to Patient:*
• Signature*
• Date*
  DD slash MM slash YYYY

• Permission to Share Records

  Our Clinical system, SystmOne, is used by other health teams in Nottinghamshire who may be involved in your care. (For example: Urgent Care Centres, Podiatry, Physiotherapy, Child Health, Out of Hours etc.)

  We need to know that you are happy to consent to us sharing your information that is held on our computer system.

  This helps to deliver better and safer care for you.

  Click here for more info on Sharing your GP record.

  Please indicate your preference below:

• Sharing Out - This controls whether your full electronic patient record can be shared with other NHS Care Services where you are treated. Please record your preference.*
  • Yes
  • No
• Sharing In - This controls whether you agree for this practic e to view information you've agreed to share at other NHS Care Services. Please record your preference.*
  • Yes
  • No
  Please note that you can change your mind at any time by informing us in writing You can also request for individual entries in your record here to be marked as 'Private'. These entries are not then shared with the other health teams even if you chose to 'Share Out'.

• What happens to my information?

  Personal and medical information about patients registered at this practice are primarily kept electronically, although some is kept in paper form.

  Some information will be sent to hospital consultants and other health professionals to whom you are referred by your GP in order to provide continued healthcare and obtain treatment for you.

  We sometimes use accredited suppliers for our communication with you, for example when we send recall letters for review clinics or medication reviews.

  All suppliers we use are checked carefully to ensure they comply with strict confidentiality protocols.

  To ensure the security of all patient information, all staff that has access to your records is covered by confidentiality clauses in their contracts and the Data Protection Act and the Freedom of Information Act.

  Our guiding principle is that we hold your records in strict confidence.

• Consent*
  I certify that the information I have provided is correct and consent to my personal and medical information being used as stated above.
• Signature*
• Date*
  DD slash MM slash YYYY

• Online Services

  You can register for online services to provide access to appointment booking, repeat prescription ordering and some sections of your medical record via the internet.

  For more info please visit NHS App.

  If you require access to online services for a child, please ask reception about our Proxy Access Protocol.

• Would you like access to Online Services?*
  • Yes
  • No

• Download NHS App

  In order to register for online services please download the NHS App. Photo ID is required to register for this service.

  If you require access to online services for a child (under 13), please ask reception about our Proxy Access Protocol.

• Your Named General Practitioner

  You may be aware that practices are required to provide all their patients with a named GP who will have overall responsibility for the care and support that our surgery provides to them.

  As one of our patients, Dr John Doddy will be your named GP.

  They will have overall responsibility for the care and support that our surgery provides to you. This does not prevent you from seeing any GP in the practice as you currently do.

  You do not need to take any further action, but if you have any questions, or wish to discuss this further with us, please contact us on 0115 9395555.

• NHS Organ Donor Registration

  Organ donations in England has changed to an opt out system for most adults.

  You still have a choice whether or not you want to become an organ donor.

  We will always ask your family to support your decision. So whatever you choose, it's really important that you let them know.

  Please visit www.organdonation.nhs.uk or call 0300 123 23 23 for more info.

• Would you like join the NHS Organ Donor Register?*
  • Yes
  • No
• To opt-out (if you're aged 18+) please visit www.organdonation.nhs.uk or call 0300 123 23 23.
• 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.*
  • Any of my organs and tissue
  • Kidneys
  • Heart
  • Liver
  • Corneas
  • Lungs
  • Pancreas
• Signature confirming my consent to join the NHS Organ Donor Register*
• Date*
  DD slash MM slash YYYY

• NHS Blood Donor Registration

  All blood types are needed, especially O negative and B negative. For more info please visit www.blood.co.uk or call 0300 123 23 23.
• Would you like join the NHS Blood Donor Register?*
  • Yes
  • No
  • Already on it
• Have you have given blood in the last 3 years?*
  • Yes
  • No
• My preferred address for donation is:
• Signature confirming my consent to join the NHS Blood Donor Register*
• Date*
  DD slash MM slash YYYY

• Proof of Identity/Address

  In order to register, you will need to upload one of the following documents from Group A & B.
• Proof of Identity Photo ID (Group A)*
  Max. file size: 128 MB.
  • a Passport
  • a UK driving licence (full or provisional)
  • a European driving licence (full)
  • a European national identity card
• Proof of Identity ID (Group A)*
  Max. file size: 128 MB.
  • a Passport
  • a Birth certificate
  • a European national identity card
• Proof of Address (Group B)*
  Max. file size: 128 MB.
  • a recent utilities bill
  • a recent council tax bill
  • a recent bank statement
• Proof of Address (Group B)*
  Max. file size: 128 MB.
  • a nursery/school letter
  • a recent utilities bill
  • a recent council tax bill
  • a recent bank statement

• Authorised Signature

• Form completed by:*
  • Patient
  • On behalf of patient
• Name*
  First Name Surname
• Relationship*
• Consent*
  I declare that the information I give on this form is correct and complete. I understand that if it is not correct, appropriate action may be taken against me.
• Signature of patient*
• Signature on behalf of patient*
• Date*
  DD slash MM slash YYYY
• Email
  This field is for validation purposes and should be left unchanged.