To register with the Practice you must complete your NHS number details. If you don’t know this information you can contact the Practice you were previously registered with and request your NHS number information. Unfortunately, we will be unable to complete your registration without this information.
We are pleased to welcome new patients however you have to live within a 2-mile radius of the Practice. Please check the catchment area before registering.
Please help us trace your previous medical records by providing the following information
- Patient Details
- Previous information
- Additional info
- Patient Declaration
Date of Birth
Place of Birth
If you are registering a child, please provide full name and address of your child’s school
Main or 1st language spoken/understood
Proof of address – Please provide a copy of a document, not older than 3 months, that provides a proof of address.
Max. size: 2.0 MB
Previous details in UK
Your previous address & postcode in UK
Name of previous GP
Address of previous GP practice
If you are from abroad
Your first UK address where registered with a GP
If previously a resident in UK, date of leaving
Date you first came to live in UK
Were you ever registered with an Armed Forces GP
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:
Address & postcode before enlisting
Service or Personnel number:
Discharge date (if applicable)
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.
NHS Organ Donor registration
Do you wish to Opt-Out from NHS Organ Donation?
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. Please tick the boxes that apply.
Please tell your family you want to be an organ donor. If you do not want to be an organ donor, please visit www.organdonation.nhs.uk or call 0300 123 23 23 to register your decision.
NHS Blood Donor registration
Carer Information (not needed for children)
Do you have a Carer?
If yes, are they registered at this practice?
Do you consent for your carer to be informed about your medical care?
Are you a Carer? (Only if you are a registered Carer)
If yes, do you look after someone who is a patient at this practice
If yes, what is their name?
Are they a
Please upload a photo ID
Max. size: 2.0 MB
Please tell us about your smoking habits, alcohol consumption, and exercises (not needed for children)
Do you smoke?
If yes, how many do you smoke a day?
Would you like advice on quitting?
Are you an ex-smoker?
Do you drink alcohol?
If yes, How much alcohol do you drink in a week (Units)?
Do you exercise?
If yes, How often do you exercise? (No. times per week and type(s) of exercise)
Have you had a Cervical Smear
Please state where, when and the result
Please ask the surgery to fill in a disclaimer form.
What illnesses have you had and when? (Existing long term conditions)
Please list any tablets, medicines or other treatments you are currently taking: (including dose and frequency)
Are there any serious disease that affect your parents, brothers or sisters ( tick all that apply)
Any other important family illness?
Please detail below any specific needs you have so that practice can ensure they are identified and accommodated by taking the appropriate action.
Are you allergic to any medicines?
If yes, please specify
Do you have any other allergies?
List any other allergies you have (pollen, animal hair or certain foods)
Please select any Sensory Impairment you have.
Are you an Assistance Dog user?
Please state any physical disabilities you have.
Please state any mental disabilities you have.
Please state any requirements you have to be able to access the practice premises.
We would like to get better at communicating with our patients. We want to make sure that you can read and understand the information we send you. If you find it hard to read our letters or if you need someone to support you at appointments, please let us know. We want to know if you need information in braille, large print or easy read. We want to know if you need an interpreter for your appointments.
Do you have any communication needs?
What type of communication needs?
Do you need a format other than standard print?
Do you have any special communication requirements?
If yes what language
We have electronic prescribing functionality, this will allow us to send your prescription electronically to your preferred choice of pharmacy, and will also save you time in collecting your prescription from the surgery.
Please give the name and address of your preferred pharmacy :
Your Care Connected
This practice is part of Your Care Connected (YCC), a potentially lifesaving local NHS record sharing service, implemented across Birmingham, Sandwell and Solihull to provide better, safer care. If you need to attend a local hospital, YCC makes it possible for the authorised health and care staff, who are caring for you, to securely access important medical information from your GP record to provide you with better, safer care. To learn more about YCC, visit the Your Care Connected website. If you are happy to take part, you do not need to do anything. If you visit one of the participating organisations, those treating you will be able to securely access vital information from your record to help improve the care you receive. If you do not want your information shared, you will need to opt out. To opt out, please complete an opt out form. Your practice will then process your request to not share your record.
Summary Care Record
If you are registered with a GP practice in England, you will already have a Summary Care Record (SCR), unless you have previously chosen not to have one. It will contain key information about the medicines you are taking, allergies you suffer from and any adverse reactions to medicines you have had in the past. Click here for more information.
Enhanced Summary Care Record
You can also choose to have additional information included in your SCR, which can enhance the care you receive. This information includes:
1. Your illnesses and health problems
2. Operations and vaccinations you have had in the past
3. How you would like to be treated – such as where you would prefer to receive care
4. What support you might need
5. Who should be contacted for more information about you
Do you wish to Opt-In for Enhanced Summary Care Record?
If you wish to opt out the Summary Care Record, please click here to complete an opt out form.
This practice uses a text messaging service to remind patients of appointments and remind patients when they are due for a review. If you provide a mobile number when registering, you will automatically be opted in to receive text messages. If you wish to opt out, please click the checkbox.
Please select one or more preferred method of contact
I declare that the information provided on this form is correct to the best of my knowledge