New Patient Application
NEW PATIENT APPLICATION
Full Name:Date of Birth:
Address:
Postcode:
Previous Address, if recently moved;
Telephone No – Mobile*……………………………….………. Home …………..………………………….
Other members of the family to join? – please add below;
Name: / Relationship: / DOB / /
Name: / Relationship: / DOB / /
Name: / Relationship: / DOB / /
Name: / Relationship: / DOB / /
Any other family members registered here? YES / NO
If yes, please give name and first line of address: …………………………………………………………
…………………………………………………………………………………………………………………………………
Current Medication: …………….………………………………………………………………………………..
………………………………………………………………………………………………………………………………..
………………………………………………………………………………………………………………………………..
Please bring all your medications with you to your new patient health check
Previous GP/Surgery name: ………………………………………………………………………………....
Please tell us how you heard about us…
Recommended
Internet
Yellow pages
Other NHS
Other please specify…………………………………………………………...………………
For Office use only:
Date form completed / Accepted? / Date patient informed / NPHC appt date / Date Scanned
/ / / Y / N / / / / / / / / /
PTO…
Score ………….
Main spoken Language: ……………………………………………………………..………………………....Country of birth: …………………………………………………………………………………….……………....
Ethnicity i.e. White, Black, Asian etc: ……………………………………….…………………………………...
*We use mobile telephone numbers provided to send appointment confirmations and reminder text messages. These will never contain any clinical information. If you do not wish to receive these free reminders please tick here
Thank you for completing a New Patient Application Form. The Doctor will now check the form and either accept or decline your application. We will only decline your application if you live outside of our practice area, if you are already registered with a local GP or if we have reached capacity with our number of patients.
Please call in to the surgery, or telephone 08448 15 10 22, after 2 days to see if your application has been accepted. If it has been accepted you will be asked to make a New Patient Health Check appointment with the Health Care Assistant. You will not be able to see the GP until you have had this check. Please bring any medication you use and a urine sample (bottles available from reception) to your Health Check appointment.
If you do not contact the surgery within 2 weeks of completing the application form, we will assume you have registered elsewhere and destroy your form.
If you do not attend your New Patient Health Check Appointment you will NOT be registered here as a patient.
If you miss your New Patient Health Check appointment we will not make you a new appointment, on the basis that if you cannot remember to attend appointments before you are registered you will miss appointments when you are a patient.