New Patient Registration




Please complete our online form

Form must be complete by an adult / be over 16 years old. For registering a child please ask at reception. 

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Patient's Details

Information we need to register you with the practice
Please note all fields marked with a * are mandatory for your registration

Service Families and Military Veterans
Preferred title
Religious affiliation
Main language
Carer status
Next of kin
Summary Care Record

Summary Care Record (SCR)

The Summary Care Record (SCR) system is designed to help both your GP and any emergency staff you contact when the surgery is closed to treat your health needs more efficiently.

Your information will be shared between your GP practice, our local hospital and Out Of Hours service. This will enable your GP surgery to access results and any visits you have at the hospital quickly and efficiently, but it also means that if you have an emergency and contact the Out Of Hours service or visit A&E they will have access to your current medications as well as allergies and are better able to treat you.

If you do not return this form, a Summary Care Record will be created for you based on implied consent

Dear Patient,

There are currently three different data sharing schemes running nationally; Local Data Sharing, the Summary Care Record and NHS Digital Data and Information Collection data sets.

It is important that patients know the difference between Local Data Sharing, the Summary Care Record and NHS Digital Data and Information Collection data sets, so that an informed choice can be made about whether you are happy for your data to be shared, or whether you wish to opt out.

We want to be sure that we give you the opportunity to decide at what level you would like to opt out of data sharing and are aware of the implications.

You can also opt out of receiving text messages from the surgery. The surgery sends texts relating to your appointments, health reminders or campaigns. Please ensure we have your correct mobile number if you want to receive these texts.

Please complete the attached form and return it to us so we can be clear about your wishes.

A data sharing agreement exists between other clinical services that we refer you to. There are local services that are run as a federation of practices; caring for patients and providing cover Monday to Sunday 8-8 at the Hub.

If a patient does not opt out, their information will be shared when immediate patient care is needed.

A Summary Care Record is an electronic record that is stored at a central location. It contains information about medicines, allergies, or reactions to medicines that a patient has had. The record does not include detailed information about a patient’s medical history. Only healthcare staff directly involved in the patient’s care who have access to this information. Having this information stored in one place makes it easier for healthcare staff to treat patients in an emergency. The information being shared could be critical in an emergency situation. If a patient does not opt out, they will automatically have a Summary Care Record; however a patient can opt out of or re-join the scheme at any time.

The NHS would like to link information from all the different places where patients receive care, to help them compare the care patients receive in one area against another, so they can see what has worked best. Information such as a patient’s postcode and NHS number, but not their name, will be used to link their records in a secure system, so their identity is protected. Information which does not reveal their identity can then be used by others, such as researchers and those planning health services, to make sure the NHS provide the best care possible for everyone. How patient information is used and shared is controlled by law and strict rules are in place to protect patient privacy. If a patient does not opt out, their information will be shared; however a patient can opt out of or re-join the scheme at any time.

Electronic Prescribing Service
Donation wishes
Resuscitation wishes and power of attorney
Smoking status
Your Personal Alcohol Consumption

alcohol consumption Image 1 unit

Your personal alcohol consumption with score 5+
Audit Score Result

you have a score of 

If you are drinking less than 14 units of alcohol per week, then your drinking is within the UK Chief Medical Officers' low risk drinking guidelines.

But if you are drinking regularly at or above the low risk guidelines of 14 units a week, or, you are drinking six or more units - if you are female - or eight or more units - if you are male - in one single session (binge drinking), please consider the increased serious risks to your health being caused by your current drinking pattern.


During the last week, how many hours did you spend on each of the following activities?

Disabilities/Accessible information standards
Family history and past medical history
for female patients only
Please use this date format: DD/MM/YYYY.
Patient Participation Group

Our surgery has a ‘Patient Participation Group’ This group plans to meet usually once a quarter to discuss our surgery, to get involved with any enhancements that we may be planning and to generally ‘help out’ if and when needed.

If you would like to be considered for a place within this group, as existing members leave or move out of our catchment area, please click below: 

Online services registration

Online services information

If you wish to, you can now use the internet to book appointments with a GP, request repeat prescriptions for any medications you take regularly and look at your medical record online. You can also still use the telephone or call in to the surgery for any enquiry.

It will be your responsibility to keep your login details and password safe and secure. If you know or suspect that your record has been accessed by someone that you have not agreed should see it, then you should change your password immediately. 

If you can't do this for some reason, we recommend that you contact the practice so that they can remove online access until you are able to reset your password. 

If you print out any information from your record, it is also your responsibility to keep this secure. If you are at all worried about keeping printed copies safe, we recommend that you do not make copies at all. 

Although the chances of any of these things happening are very small, you will be asked that you have read and understood the following before you are given login details. 

  • Forgotten history: There may be something you have forgotten about in your record that you might find upsetting.
  • Abnormal results or bad news: If your GP has given you access to test results or letters, you may see something that you find upsetting to you. This may occur before you have spoken to your doctor or while the surgery is closed and you cannot contact them.
  • Choosing to share your information with someone: It's up to youwheter or not you share your information with others - perhaps family members or carers. It's your choice, but also your responsibility to keep the informationsafe and secure. 
  • Coersion: If you think you may be pressured into revealing details from your patient record to someone else against your will, it is best that you do not register for access at this time. 
  • Misunderstood information: Your medical record is designed to be used by clinical professionals to ensure that you receive the best possible care. Some of the information within your medical record may be highly technical, written by specialists and not easily understood. If you require further clarification, please contact the surgery for a cleaer explanation.
  • Information about someone else: If you spot something in the record that is not about you or notice any other erros, please log out of the system immediately and contact the practice as soon as possible. 

What happens to my information?

Personal and medical information about patients registered at this practice are primarily kept electronically, although some is kept in paper form. Some information will be sent to hospital consultants and other health professionals to whom you are referred by your GP in order to provide continued healthcare and obtain treatment for you.

We sometimes use accredited suppliers for our communication with you, for example when we send recall letters for review clinics or medication reviews. All suppliers we use are checked carefully to ensure they comply with strict confidentiality protocols.

To ensure the security of all patient information, all staff that has access to your records is covered by confidentiality clauses in their contracts and the Data Protection Act and the Freedom of Information Act. Our guiding principle is that we hold your records in strict confidence.

I certify that the information I have provided is correct and consent to my personal and medical information being used as stated above.

Privacy Consent

This form collects personal and medical information about you. We use this information to allow the practice team to contact you. Please read our Privacy Policy to discover how we protect and manage your submitted data.


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