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New Patient Registration Form

Provide the details below to register with the Practice. A member of staff may need to telephone you to confirm certain aspects of your Registration.

New Patient Registration Form
Next of Kin
Military
If you are From Abroad
Communication Requirements
Ethnicity / Language
Medical History
Carers
Smoking
Family Medical History
Lifestyle Alcohol
Female Patients Only
Data Sharing

As part of the NHS, our surgery aims to provide you with the highest quality of health care. To do this we must keep records about you, your health and the care we have provided or plan to provide to you. These records may include:

• Basic details about you such as address, telephone number, date of birth, next of kin

• Contact we have had with you such as clinical visits

• Notes and reports about your health

• Details and records about your treatment and care, including test results

• Relevant information from people who care for you and know you well such as health professionals and relatives

Everyone working for the NHS has a legal duty to keep information about you confidential. We have a duty to maintain full and accurate records of the care we provide to you.

Some information will be held centrally to be used for statistical purposes. In these instances we take strict measures to ensure that individual patients cannot be identified. We use anonymous information, wherever

NHS Organ Donation
NHS Blood Donor
Please complete if you live in another EEA country, or have moved to the UK to study or retire, or if you live in the UK but work in another EEA member state.
If you are visiting rom another EEA country and do not hold a current EHIC or PRC, you may be billed for the cost of any treatmnent received outside of the GP practice including at a hospital

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 and is accessed over a secure connection by nominated staff. We have 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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