New Patient Registration

If you live within our Practice Boundary and would like to register with the practice please use this form.

If registering your child under 5 years of age

To register, you will need to bring in your child’s Red Book (Personal Child Health Record) or provide us with a certified record of previous immunisations and complete a registration form. If you do not have the Red Book or have lost it then please contact our Reception Team. Immunisation records are very important for the wellbeing of your child: collecting this information will ensure that we have an up to date record, including when the next vaccinations are due.

New Patient Registration

If you are human, leave this field blank.

Patient's Details

Title *

Mr

Mrs

Miss

Ms

Other

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:

Please check this box if you are registering a new baby:

I am registering a new baby

Are you registering a child under the age of 16? *

Yes

No

Please specify which Practice both parents are registered with: *

Trafalgar Medical Group Practice

Other

Please specify:

Home Address: *

Postcode: *

Town and Country of birth: *

Home Phone Number:

Mobile Phone Number:

Work Phone Number:

Email Address: *

Can we contact you by text?

Yes

No

Can we contact you by email?

Yes

No

Would you like to be registered for online services?

Yes

No

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:

Emergency Contact

Full Name:

Relationship to you:

Phone Number:

Are they your Next of Kin?

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

Have you previously been registered with a GP in the UK? *

Yes

No

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

Country of Birth:

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.

HM Armed Forces Veteran

Have you ever done Military Service?

Yes

No

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