New Patient Registration Form

1. Background Details

Contact Details

NHS Number

Name *

Previous Surname (if applicable)

Gender *

Date of Birth *

Home Telephone

Work Telephone

Address *

Address

Postcode

City

Country

Previous Address

Postcode

City

Country

Mobile Number

Do you consent to be contacted by SMS on this mobile number.

Yes

No

Email

Do you consent to be contacted by email

Yes

No

Next of Kin

Next of kin Name *

Telephone Number *

Relationship *

Have you been registered in the NHS before? *

Yes

No

If ‘no’ please state date entered UK

Other Details

Previous GP

Name *

Address *

Address

Postcode

City

Country

Country of Birth *

Ethnicity *

Religion

Housing

Employment

Armed Forces

Military Veteran

Family member

Communication Needs

Language

What is your main spoken language? *

Do you need an interpreter? *

Yes

No

Communication

Do you have any communication needs? *

Yes

No

Learning disability

Do you have a Learning Disability? *

Yes

No

(If yes please request a Learning Disability Screening Tool form)

Carer Details

ARE YOU a carer? *

Yes – Informal / Unpaid Carer

Yes – Occupational / Paid Carer

No

Do you HAVE a carer? *

Yes

No

Your carer’s details

Name*

Telephone Number

Relationship

* Only add carer’s details if they give their consent to have these details stored on your medical record