New Patient Registration Form (GMS1) V2

Fields marked "REQUIRED" are compulsory. You should only send this form if you are sure that you are eligible to join this practice. Sending this form will NOT automatically register you with the surgery. Your details will be held at the surgery for a limited period of time.

Last Updated: 23/09/2021

Patients Details















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




If you are from abroad



Service Families and Military Veterans

As a practice, we fully support the Armed Forces Covenant. We can only do this if we know our patients connections to the Armed Forces. Please tick the below boxes that apply to you:

About You











Contacting you

We will use your contact details to send reminders about appointments, reviews and other services which may be of benefit in your medical care





Summary Care Record

Summary Care Record (SCR) If you decide to have a SCR, it will contain important information about any medicines you are taking, allergies you suffer from and any bad reactions to medicines that you have had it will also include basic information about your current diagnoses. Giving healthcare staff access to this information can prevent mistakes being made when caring for you in an emergency or when your GP practice is closed. Your Summary Care Record will also include your name, address, date of birth and your unique NHS Number to help identify you correctly. If you and your GP decide to include more information it can be added, but only with your express permission. For more information: Phone 0300 123 3020 or visit www.nhscarerecords.nhs.uk

Electronic Prescribing Service (EPS)

The EPS allows prescribers – such as GPs and practice nurses to send prescriptions electronically to a dispenser (such as a pharmacy) of the patient’s choice. This makes the prescribing and dispensing process more efficient and convenient for patients and staff. The NHS aim that by 2020 they will hopefully be paper free or a paper-lite service. To help achieve this, we would encourage all patients to opt for electronic prescribing.


Donation wishes

If you live in England, Wales or Jersey, are not in a group excluded from opt out legislation and you have not registered an organ donation decision, it will be considered that you agree to be an organ donor. This is known as deemed consent. 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.


Resuscitation wishes and Power of Attorney

If YES to either of the below questions, please supply details of who holds this and where (and supply a copy for your medical notes). Details


Smoking Status

Stopping smoking is not easy but it can be done, and there is now a comprehensive, NHS Smoking Cessation Service offering support and help to smokers wanting to stop, with cessation aids available on NHS prescription. If you would like help and advice on how to give up smoking, please contact https://www.quit4life.nhs.uk/ or ask at reception.





Alcohol Intake

If you would like help and advice on how to reduce your alcohol intake, please contact https://www.drinkaware.co.uk or ask at Reception.




General Practice Physical Activity Questionnaire

Info about that here



In the last week,. how long have you spent on the following activities?

Please answer whether you are in employment or not.






Non-Attendance of Appointments

There are increasing pressures upon all doctors and nurses to reduce waiting times and increase patient access. Sadly, a number of appointments are wasted each week due to patients not giving us notice that they would not be attending appointments. In addition, nursing and administrative time is wasted where records and/or equipment needs advance preparation. We would appreciate it, if you know you cannot attend an appointment, that you cancel it as early as possible. We will continue to monitor missed appointments. Persistent failure to either cancel or attend may result in removal from our list. Zero Tolerance Our practice staff are here to help you. Our aim is to be as polite and helpful as possible to ALL patients. If you consider that you have been treated unfairly or inappropriately please ask the reception team to contact a member of the management team who will be happy to address your concerns. However, shouting and swearing at practice staff will NOT be tolerated under ANY circumstances and patients who are abusive may be removed from the practice list. Please help us to help you

Height/Weight




Disabilities/Accessible Information Standards

As a practice we want to make sure that we give you information that is clear to you. For that reason we would like to know if you have any communication needs.






Family History and past medical history




Allergies


For female patients only





Patient Participation Group

We would like to know how we can improve our service to you and how you perceive our surgery and staff. 

To help us with this, we have set up a virtual patient representation group so that you can have your say. We will ask the members of this representative group some questions from time to time, such as what you think about our opening times or the quality of the care or service you received. We will contact you via email and keep our surveys succinct so it shouldn’t take too much of your time.

We aim to gather around a hundred patients from as broad a spectrum as possible to get a truly representative sample. We need young people, workers, retirees, people with long term conditions, people with disabilities and people from non-British ethnic groups.

Code of Conduct

  1. The PPG is not a forum for individual complaints.
  2. PPG members will not discuss their own personal health issues, medical condition or treatment in any emails or survey responses.
  3. The PPG is not to be used in pursuit of specific or personal health campaigns for example in connection with access to special treatments.
  4. Confidentiality will be paramount. Email addresses of members of the PRG will not be disclosed to other members, unless their express consent is given. The PPG will not require information about individual patient’s illness, condition or treatment and should not seek it.
  5. Members of the PPG are expected to conduct themselves with courtesy and consideration for others
  6. Members of the PPG will not approach the media without the prior approval of the practice.