Adult New Patient Registration

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

To register a new patient you will need to live within our practice boundary.

Once this form is submitted you will be asked to submit two forms of ID to the practice.

Please note that each Family member will need to submit their own individual form in order to register with the practice. Please use our Children and Young Persons under 16 New Patient Registration form for patients under the age of 16.

New Patient Registration

If you are human, leave this field blank.

Patient's Details

Title *

Mr

Mrs

Miss

Ms

Other

Marital Status

Single

Married

Other

Please specify:

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: *

Does anyone else live at this address, who is registered at Eleanor Cross Healthcare?

Yes

No

Full Name:

Date of Birth: *

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

Postcode: *

Town and Country of birth: *

Home Phone Number:

Mobile Phone Number:

Work Phone Number:

If we need to contact you during working hours 8am - 6.30pm, please indicate your preferred number: *

Home Number

Mobile Number

Work Number

Email Address: *

Any responses we send will go to this email address.

Main Occupation:

Can we contact you by text? *

Yes

No

Can we contact you by email?

Yes

No

Which practice would you like to attend to complete your registration? *

Delapre Medical Centre

Whitefields Surgery

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

First Language: *

Religion:

Emergency Contact

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

Allergies

Do you have any allergies?

Yes

No

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

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.

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

If you are a Carer, we will refer you to Northamptonshire Carers to see if they can offer you any help or support. Please tick the box if you do NOT wish to be referred.

Armed Forces

Have you ever served in the Armed Forces?

Yes

No

Service Number:

Enlistment Date:

Discharge Date:

Are you a member of a military family?

Yes

No