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BAME Patient Experience Survey

New Patient Registration

Everyone is welcome in general practice – lack of ID will not stop you registering at our practice.

 

You can register online:

  • by completing the online registration form below. Please be advised it can take up to 10 working days to be registered once you have submitted the form. 
  • through Patient Access. You will need to contact reception first to signup for this service.

Alternatively you can download the registration form here. Once completed please bring it into the surgery.

Temporary Residents

Click here for the form if you need to register as a temporary resident

Patient Details
For example - I require minimum size 14 font in any communications.
This allows you see some results and book some of your own appointments online.
Ethnicity
Health Details
Drugs and Alcohol

Alcohol - alcohol use can affect your health and can interfere with certain medications and treatments. Yours answers will remain confidential so please be honest.

(1 unit = ½ pint beer or lager, 1 single measure of spirit or 1 medium glass of wine)
Medical History

Do you have, or have had any serious health problems (including operations/long term conditions)?

Family Medical History

Have any of your immediate relatives (brothers/sisters/parents) had any of the following?

Hospital Care

The doctor may discuss with you the possibility of transferring your care to a local hospital

If yes, please complete details below

Other Information
Females Only

Privacy Protection

Information submitted through secure forms is used only for the purposes of processing your request. We may be in touch with you in relation to the information submitted.

All Information submitted through secure forms is secured with a private key known only to the GP practice and is accessed over a secure connection by nominated Practice staff. Our practice has a strict confidentiality policy.

This information is not shared with any third party organisations.

This information is retained for up to 28 days.

Learn more about our Privacy Policy and Terms of Use. Should you have any concerns about sending your personal details using the web, please use one of the alternative methods offered by our organisation.


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