New Patient Registration

To start the registration process with our practice you will be asked to fill in a registration form AND health questionnaire. You can complete these two forms by either calling into reception or completing them online - using the form below.

PLEASE NOTE - All fields are mandatory including your NHS number. You can obtain your NHS number through your existing GP. 

If you do not have a record of your NHS number or are new to the country, your online form will NOT be accepted. Please visit reception in person, in addition you will also be required to provide documentation to verify your identity and address. 

As part of the registration process we ask if you are currently taking medication that you attend a new patient health check with our Clinical Assistant. This is not a condition of your registration but does give an important opportunity to ensure that we are fully aware of your present medical requirements, as it may be some time before we receive your medical records.

Please note, you will not be registered as a patient until you have completed all of the above actions required.

PRACTICE AREA

The surgery provides general medical services for the geographical area of Coventry

To ensure that we can provide the appropriate standard of medical care, which includes home visits where necessary, we are only able to accept new patients from within this boundary area.


New Patient Registration

Please complete the form to register yourself with our surgery.
Any field marked with * is mandatory

Personal details

Please enter your NHS number if previously registered with NHS
NHS Number
Title
Gender
First Name*
Last Name*
Date of Birth*
Country of Birth*
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Current address details

Address Line 1*
Address Line 2
Town*
County
Postcode*

Contact details

Home Phone Number
Mobile Number
Work Number
Email Address*
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Previous GP details

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

Your previous address:

Previous Address 1
Previous Address 2
Previous Town
Previous County
Previous Postcode

Provide the name and address of the previous Doctor while at that address:

Previous Doctor Name
Previous Doctor Address
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If you are from abroad

Check the box below if the address is the same as the previous tab:

Same UK address
Your first UK address where registered with a GP
Date you first came to live in UK
If previously resident in UK, date of leaving

If you are returning from the armed forces

Address before enlisting
Service or personnel number
Enlistment date
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Medical history

Height
Weight

Smoking

Do you smoke?
Never
Current smoker
Ex-smoker
Date stopped smoking

Drinking alcohol

How often do you have a drink containing alcohol?

How often?

How many units of alcohol do you drink on a typical day when you are drinking?

Units on a typical day?

How often have you had 6 or more units if female, or 8 or more if male, on a single occasion in the last year?

Units on a single occasion?
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Medical history continued

Do you suffer with any of the following medical conditions?
Asthma
Heart disease
Diabetes
Epilepsy
Hypertension
Hypothyroidism
Learning Disabilities
Mental Health
Stroke
Do you have any family history of the following medical conditions?
Asthma
Heart disease
Diabetes
Epilepsy
Hypertension
Hypothyroidism
Learning Disabilities
Mental Health
Stroke

If you have checked any of the family history boxes above, please outline what relation has/had what condition below:

Family relations and conditions
Please detail any allergies
Please list any regular medications you take
Date of last tetanus
Female patients only: What was the date of your last smear test?
What was the result of your last smear test?
What is your occupation?
What is your ethnic origin?
What is your main spoken language?*
Do you require an interpreter?
Yes
No
Are you cared for by someone?
Yes
No
Do you care for someone else?
Yes
No
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Additional Information

NHS organ donor registration

I want to register my details on the NHS Organ Donor Register as someone whose organs can be used in the event of my death.

NHS Organ Donor Register
Any of my organs or tissue
Kidneys
Heart
Liver
Corneas
Lungs
Pancreas

NHS Blood donor registration

I would like to join the NHS Blood Donor Register as someone who may be contacted and would be prepared to donate blood:

I am prepared to donate blood
Have you given blood in the last 3 years?
Yes
No

Final details

How did you hear about this practice?
Were you previously registered with another local practice?
Yes
No
If yes, please state reason for changing surgery
Do you consent to us contacting you from time to time by email?*
Yes
No
Do you consent to us contacting you from time to time by text message?*
Yes
No

We have a patient participation group who meets with the practice on a quarterly basis. If you are interested in joining the group please check the box below and we will get in touch:

I am interested in the patient participation group
Please subscribe me to your surgery email newsletter

Please complete the instructions below, which will either be a checkbox or a question. This helps us avoid spam.

Spam protection*
 
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