New Patient Registration

If you would like to register with the practice please use this form.

We register New Patients if they are in our catchment area which includes most of the Stevenage area.

We have been advised by NHS England not to register patients who are already registered with a gp within Stevenage, especially if have a underling medical condition or are self isolating, These process will be reviewed in June of this year.

Find out about Temporary Registration.

New Patient Registration

If you are human, leave this field blank.

Patient's Details

Please select which surgery you would like to register with: *

Stanmore Road Surgery

The Poplars Surgery

St Nicholas Health Centre

Canterbury Way Surgery

Title *

Mr

Mrs

Miss

Ms

Other

Please specify:

Surname: *

Previous Surnames:

First Name(s) *

Date of Birth: *

Please use this date format: DD/MM/YYYY.

Gender *

Male

Female

Indeterminate

NHS Number: *

Home Address: *

Postcode: *

Town and Country of birth: *

Home Phone Number:

Mobile Phone Number:

Work Phone Number:

Email Address: *

Please tick all the statements that apply to you:

I live in Stevenage.

I live outside Stevenage and the receptionist has explained to me the services I will not receive.

I consent to receive text messages for appointment reminders etc.

Previous Details

Previous address in UK:

Please include postcode.

Name and address of previous GP:

If you are from abroad

Registering for the first time in the UK

Date you came to live in the UK:

Please use this date format: DD/MM/YYYY.

If you are returning from abroad

Previously been a resident in the UK

Date you left the UK:

Please use this date format: DD/MM/YYYY.

Date you returned to the UK:

Please use this date format: DD/MM/YYYY.

Emergency Contact / Next of Kin

Full Name: *

Relationship to you: *

Phone Number:

Are they your Next of Kin? *

Yes

No

Do you give us permission to discuss your medical records with them? *

Yes

No

If you are registering someone under 16

Who else lives in your household?

Mum

Dad

Step Parent

Parents Partner

Grandmother

Grandfather

Foster Carer

Guardian

Siblings

Other

Other Family Members:

Does this child have contact with any of the following?

Hospital Specialist

Health Visitor

Social Worker

Any other health professional

Other health professional:

Has this child ever been under a child protection plan?

Yes

No

Does the above Emergency Contact / Next of Kin have parental responsibility for this child?

Yes

No

Name of Responsible Adult:

Relationship to Child:

Phone Number:

Home Address:

Nominated Pharmacy Information

My Chosen Pharmacy is * Please select from the following... Stearns Pharmacy, 48 High Street, Stevenage SG1 3EF Medix Pharmacy, 84 High Street, Stevenage SG1 3DW Tesco Pharmacy, The Forum, Stevenage SG1 1ES Lloyds Pharmacy inside Sainsbury's, Hitchin Road, Stevenage SG1 4AE Md Chemist, 4 Filey Close, Symonds Green, Stevenage SG1 2JW Other

Other Pharmacy Name, Address and Postcode: *

Communication Needs

Do you have any communication needs?

Hearing Aid

Large Print

British Sign Language

Makaton Sign Language

Lip Reading

Braille

Guide Dog

Do you have a learning disability?

Yes

No

Please request a Learning Disability Screening Tool form.

Carers

Do you have a carer? *

Yes

No

Are you a carer for someone? *

Yes

No

Name of carer:

Phone Number:

Address:

Do you give us permission to discuss your medical record with your carer? *

Yes

No

Ethnicity

Please specify the ethnic group you consider you belong to: *

White British

White Irish

Other White

Black Caribbean

Black African

Other Black

Black Caribbean and White

Black African and White

Other Mixed

Indian

Pakistani

Bangladeshi

Other Asian

I do not wish to state

Other ethnic group

Please state:

Do you speak English? *

Yes

No

Do you read English? *

Yes

No

Do you require an interpreter? *

Yes

No

First Language: *

Allergies

Do you have any allergies? *

Yes

No

Please specify what you are allergic to, what happens and when you had your first reaction: