Adult Registration Form

Fields marked "REQUIRED" are compulsory. You should only send this form if you are sure that you are eligible to join this practice - please check our catchment area. Your details will be held at the surgery for a limited period of time. Sending this form does NOT guarantee registration.

Last Updated: 13/09/2021

Patients Details














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





If you are from abroad




If you are returning from the armed forces




Complete Registration





Next of Kin

Who can we contact in case of an emergency? (preferably in the UK but if not please add the dialling code)






New Patient Questionnaire

Please take time to complete this questionnaire. It is important that we have as much information about you to give you the best service of care.








Present Health Status

















Alcohol Intake

Please tell us about your alcohol intake. Unit Indicator: 1 pint of 5.2% larger or 1 250ml glass of 12% wine = 3 units, 1 pint of 6% cider = 3.4 units, 1 pint of 4% ale = 2.3 units, 1 double measure of gin or vodka = 2 units, 1 bottle of 12% wine = 9 units.












Services & Communications









Meningitis ACWY & MMR Vaccination for new students

As you may be aware there has been a small increase in the rate of meningococcal meningitis or septicaemia in recent years. It is still an uncommon condition but young people attending higher education for the first time, especially when living in halls of residence or other shared accommodation, are at greater risk of this disease particularly in the first few weeks of their first term at university. Meningitis ACWY immunisation is part of the UK immunisation programme however ALL students should check their immunisation records to ensure that they have received it since their 10th birthday. During the last few years a number of Universities including Birmingham, have seen an increase in cases of Mumps amongst students. This can be a debilitating infection in young people with the possible risk of complications and those who become ill are isolated hence disrupting their education. Department of Health advice is that all those entering higher education should have had two immunisations against measles, mumps and rubella (known as MMR). Please, therefore, ensure that you are fully immunised. To achieve maximum protection you should have been immunised against Meningitis ACWY and MMR before attending the University, but if you have not had it we urge you to book an appointment with the Practice Nurse.

Opt Out Form for Sharing Data from your Medical Records

There are two data sharing projects currently in progress and these are: • SCR – Summary Care Record • YCC – Your Care Connected (formally known as Central Care Record) It is important to note that each of these projects run a separate opt out system. Therefore if you wish to opt out of one or more of these projects please complete the form below.


Online Access

You can sign up to online access to enable you to book appointments, send us messages, order repeat medications, view test results, vaccination history and your coded medical records.

SUPPLEMENTARY QUESTIONS | PATIENT DECLARATION for all patients who are not ordinarily resident in the UK

Anybody in England can register with a GP practice and receive free medical care from that practice. However, if you are not 'ordinarily resident' in the UK you may have to pay for NHS treatment outside of the GP practice. Being ordinarily resident broadly means living lawfully in the UK on a properly settled basis for the time being. In most cases, nationals of countries outside the European Economic Area must also have the status of 'indefinite leave to remain' in the UK. Some services, such as diagnostic tests of suspected infectious diseases and any treatment of those diseases are free of charge to all people, while some groups who are not ordinarily resident here are exempt from all treatment charges. More information on ordinary residence, exemptions and paying for NHS services can be found in the Visitor and Migrant patient leaflet, available from your GP practice. You may be asked to provide proof of entitlement in order to receive free NHS treatment outside of the GP practice, otherwise you may be charged for your treatment. Even if you have to pay for a service, you will always be provided with any immediately necessary or urgent treatment, regardless of advance payment. The information you give on this form will be used to assist in identifying your chargeable status, and may be shared, including with NHS secondary care organisations (e.g. hospitals) and NHS Digital, for the purposes of validation, invoicing and cost recovery. You may be contacted on behalf of the NHS to confirm any details you have provided.






NON-UK EUROPEAN HEALTH INSURANCE CARD (EHIC), PROVISIONAL REPLACEMENT CERTIFICATE (PRC) DETAILS and S1 FORMS

Complete this section 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. Do not complete this section if you have an EHIC issued by the UK. If you are visiting from another EEA country and do not hold a current EHIC (or Provisional Replacement Certificate (PRC)/S1, you may be billed for the cost of any treatment received outside the GP practice, including at hospital).














How will your EHIC/PRC/S1 data be used?

By using your EHIC or PRC for NHS treatment costs your EHIC or PRC data and GP appointment data will be shared with NHS secondary care (hospitals) and NHS Digital solely for the purposes of cost recovery. Your clinical data will not be shared in the cost recovery process. Your EHIC, PRC or S1 information will be shared with The Department for Work and Pensions for the purpose of recovering your NHS costs from your home country.