New Patient Registration

If you have been asked by the practice to complete a new patient registration, please fill out this form. To register a new patient you will need to live within our practice boundary.

Please note that incomplete forms will be rejected.

Please also read the Prescription Request Process information page.

Once completed you will need to provide the documents below (these must be dated within the last 3 months). If you are unable to provide any of the necessary documentation please speak to reception about your registration.

  • You need to provide your NHS number at the time of registration (you will be able to obtain this by asking your previous surgery or any hospital letters you may have will have your NHS number on)
  • One form of photographic ID (e.g. passport, UK drivers licence, student card)
  • One proof of address (e.g. gas, water, electricity, phone or council tax bill, bank statement, or a letter from your landlord or housing department to confirm your residency. This must be dated in the last 3 months)

 

Please note the Registration hours are Monday to Friday 14:00-18:00 at The Wallace Health Centre. If the required documents are not provided within 2 weeks from your initial online registration request please note your request will be cancelled.

Register as a New Patient

Patient Details

Title
Please use the format DD/MM/YYYY
Sex: *
I consent to the practice contacting me by text message for the purposes of appointment reminders and health promotion: *
I consent to the practice contacting me by email for the purposes of appointment reminders and health promotion: *

Note: The practice does not share any contact details with any external organisations.

Next of Kin Details

Ethnic Origin

Ethnicity: *
If English is your second language would you require an interpreter to assist you?

Smoking Status

Are you a current smoker? *
Are you an ex-smoker? *
Do you smoke an electronic cigarette? *

Alcohol Consumption

This is one unit of alcohol:

Amount of different types of drink representing one unit of alcohol

And each one of these, is more than one unit:

Amount of different types of drink representing more than one unit of alcoholAmount of different types of drink representing more than one unit of alcohol
Teetotal:

Height and Weight

Blood Pressure:

If you do not have a home machine to test your blood pressure, please use the machine at the surgery.
/

Exercise:

Family History

Is there a history of any of the following in your family? (father, mother, brother, sister etc.)

Do you Suffer from any of the Following Conditions?

Asthma *
Atrial Fibrillation *
Cancer *
Chronic Kidney Disease *
Chronic Obstructive Pulmonary Disease (COPD) *
Coronary Heart Disease *
Dementia *
Depression *
Diabetes Mellitus *
Epilepsy *
Heart Failure *
Hypertension *
Learning Disabilities *
Mental Health Problems *
Osteoperosis *
Palliative Care *
Peripheral Arterial Disease *
Rheumatoid Arthritis *
Stroke and Transient Attacks *
HIV *
Hepatitis *

Medical History

Do you have any drug/non drug allergies? *

Cervical Screening Information

Have you ever had a cervical smear test?
Was your cervical smear test done overseas?
Where was the cervical smear test done?
Was the result normal?

Medication

Please note before registering: ensure that you have got enough supply from your previous surgery as the registration process might take up to 10 working days.

Are you taking any regular medications? *

Summary Care Record

Please note that you are automatically enrolled into this system. If you would like to opt out, please complete the Summary Care Record Opt Out form.

Do you consent to your records being shared? *

Please complete the Summary Care Record Opt Out Form.

Latent TB

Have you lived in one of the countries below for a period of 6 months or more within the last 5 years? Please select any that apply: