Adult New Patient Registration Completing this form is the first step to registering with the practice. You will need to provide some identification on your first visit to the practice. Patient DetailsHealth InformationFurther Information0% Complete1 of 3 Patient's Details Radio Buttons * Mr Mrs Miss Ms Other I declare to the best of my belief this information is correct. An audit trail is available at the practice for inspection by the HA’s authorised officers and auditors appointed by the Audit Commission. Surname * Date of Birth * Please use this date format: DD/MM/YYYY. First names * NHS Number Previous surnames/Maiden name Gender * Male Female Other Marital Status Home address * Postcode * Town and country of birth * Mobile Phone Number * Home Phone Number * Email Address * Are you currently employed? Full Time Part Time Self Employed Unemployed Which best describes you: Retired Student Housewife/Househusband/Homemaker Other Your first choice of contact method: * Letter Email Text Phone Ethnicity Please select your ethnicity: * White English White Northern Irish White Scottish White Welsh White Irish White Cypriot White Greek White Greek Cypriot White Turkish White Turkish Cypriot White Itialian White Polish White Kosovan White & Black Caribbean White & Black African White & Asian Bangladeshi/British Bangladeshi British Asian Indian/British Indian Black British Black Caribbean Black African Black Nigerian Black Somali Chinese Jewish Iranian Arab Latin American North African Do not wish to disclose Other What is your second language? (if applicable) Do you need an interpreter? * Yes No Please select your religion: Church of England Catholic Other Christian Buddhist Hindu Muslim Sikh Jewish Jehovah's Witness No Religion Prefer not to state NHS Regulations 2015 Self Declaration * I am a British resident and entitled to full NHS care I hold a non-UK issued European Health Insurance Card (EHIC) I hold an S1 form (entitlement to health care in another European Economic Area country for a limited duration) Next of Kin & Other Relatives Next of Kin Full Name: Relationship to patient: Contact Phone Number: Please list other relatives of your home registered with us: Please include name, relationship & DOB. Carers Are you a carer for someone who is ill, frail, disabled, has substance problems or has mental health needs? * Yes No Do you have a carer? * Yes No Carer's Name: * Phone Number: * Address: * Relationship to you: Are you housebound? Yes No Do you need help with mobility/hearing/speaking? Wheelchair/hearing aid/braille/lip reading etc. Medical Records Please help us trace your previous medical records by providing as much of the following information as possible. Your previous address in UK. Your previous address in UK * Name of previous doctor * Address of previous doctor * If you are returning from the armed forces Address before enlisting Service or personnel number Enlistment date Please use this date format: DD/MM/YYYY. If you are from abroad Your first UK address where registered with a GP If previous resident in UK, date of leaving Please use this date format: DD/MM/YYYY. Date you first came to live in UK Please use this date format: DD/MM/YYYY.