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

Patient's Details

Title *
Marital Status
Please use this date format: DD/MM/YYYY.
Gender *
Does anyone else live at this address, who is registered at Eleanor Cross Healthcare?
Please use this date format: DD/MM/YYYY.
If we need to contact you during working hours 8am - 6.30pm, please indicate your preferred number: *
Any responses we send will go to this email address.
Can we contact you by text? *
Can we contact you by email?
Which practice would you like to attend to complete your registration? *

Ethnicity

Please specify the ethnic group you consider you belong to:
Do you speak English?
Do you read English?

Emergency Contact

Are they your Next of Kin?
Do you give us permission to discuss your medical records with them?

Allergies

Do you have any allergies?

Previous Details

Please include postcode.

If you are from abroad

Registering for the first time in the UK

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

If you are returning from abroad

Previously been a resident in the UK

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

Carers

Do you have a carer?
Are you a carer for someone?
Do you give us permission to discuss your medical record with your carer?

Armed Forces

Have you ever served in the Armed Forces?
Are you a member of a military family?