Registration Form

REGISTRATION WITH THE PRACTICE

To register online please ensure that you complete all fields on both the new patient registration form and the health questionnaire that follows once you click ‘submit’.

Please note that we are only able to accept online registrations for patients who have been previously registered with the NHS in the UK.

If you are new to the country you will need to register in person at the practice. Please download and print the new patient registration form and  bring to the practice with two forms of photo ID and proof of address to register.

Patients have the right to express a preference from whom they receive services. This preference will be recorded and the practice will endeavour to comply with any reasonable preference expressed but need not do so if the person requested has reasonable grounds for refusing to provide the services or does not routinely provide the service requested. All new patients will be invited to participate in a consultation.  

CATCHMENT AREA

Wellesboune, Kineton and surrounding villages. For specific information about your eligibility to join the practice list, please contact our reception team.

Your Details
Communication Preferences
No contact information will be shared with any third parties. without your explicit consent.
Your Registration Details - help us trace your previous medical records by providing the following information

You can get this from your previous GP Surgery

If you are from abroad
If you are returning from the Armed Forces
If you need your doctor to dispense medicines and appliances*

*Not all doctors are authorised to dispense medicines

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.

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.

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.

About You
If you would like more information on carers, please contact the reception team.
If you would like help giving up smoking, please make an appointment to see one of our practice nurses.
Please indicate the unit of measurement (feet, inches, cm etc...)
Please indicate unit (e.g. Stones, kg, lbs etc…)
(1 unit = 1 small glass of wine / ½ pint of beer/lager)
Add up the scores next to your answers
Your medication
Please include full name, stength and dose instructions for each medication
Medical History
Your Family History
Vaccination History
Online Access

The Practice offers our patients the ability to book, change, cancel appointments and request repeat prescriptions online via a secure online portal or smart phone app.

Please indicate your consent below if you would like to sign up to this service.

We also offer advanced access to full medical records, test results and consultation data. Please visit the Practice with a form of ID if you would like to sign up to this advanced service.

CURRENTLY THIS SERVICE IS ONLY AVAILABLE TO PATIENTS OVER 16 YEARS OLD
NHS Organ Donor Registration
NHS Blood Donor Registration
All blood types are needed, especially O negative and B negative. Visit www.blood.co.uk or call 0300 123 23 23.
Summary Care Record

Your Summary Care Record is a short summary of your GP medical records. It tells other health and care staff who care for you about the medicines you take and your allergies. This means they can give you better care if you need health care away from your usual doctor's surgery:

•in an emergency

•when you're on holiday

•when your surgery is closed

•at out-patient clinics

•when you visit a pharmacy

Staff will ask your permission to look at your SCR (except in an emergency where you are unconscious, for example) and only staff with the right levels of security clearance can access the system, so your information is secure. You can ask an organisation to show you a record of who has looked at your SCR - this is called a Subject Access Request.

SCRs improve care, but if you don't want to have one you can opt out. Tell your GP or fill in an opt-out form and give it to your GP practice.

Legal declaration
Select yes to continue

Privacy Protection

Information submitted through secure forms is used only for the purposes of processing your request. We may be in touch with you in relation to the information submitted.

All Information submitted through secure forms is secured with a private key known only to the GP practice and is accessed over a secure connection by nominated Practice staff. Our practice has a strict confidentiality policy.

This information is not shared with any third party organisations.

This information is retained for up to 28 days.

Learn more about our Privacy Policy and Terms of Use. Should you have any concerns about sending your personal details using the web, please use one of the alternative methods offered by our organisation.