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New Patient Registration

If you have recently moved into the area and live at a permanent address within our practice boundaries (Click here for the practice area map), then we will be able to register you with our practice.

All new patients are asked to complete a health questionnaire and a registration form. These require various details, such as your previous address, address of your last GP, medical history etc. These forms are required as your medical records may take time to arrive at the practice from your previous doctors.  You can complete this form online further down the page.

Please bring your medical card when registering at the practice and a form with details of identification and your address.

If you only have a temporary address, or are outside of our practice boundaries, then we will be unable to register you.

If you have a specific request or situation that you wish to raise, then please put this in writing to the practice co-ordinator. This request will be considered by the practice and a written response will be given.

All our patients are provided with a named GP. However this doesn't prevent patients seeing any doctor of their choice at the practice. 

We have two online applications Patient Access and Birmingham and Solihull App. Both applications will allow you to book appointments, access your medical records and manage your medication. For more information don’t hesitate to ask at reception or pick up one of our leaflets.

Before completing the form below, click here to download information on online services and read this first.

New Patient Registration
Please help us trace your previous medical records by providing the following information
If you are from abroad
Were you ever registered with an Armed Forces GP

These questions are optional and your answers will not affect your entitlement to register or receive services from the NHS but may improve access to some NHS priority and service charities services.

If you need your doctor to dispense medicines and appliances*

* Not all doctors are authorised to dispense medicines

NHS Organ Donor registration

Please tell your family you want to be an organ donor. If you do not want to be an organ donor, please visit www.organdonation.nhs.uk or call 0300 123 23 23 to register your decision.

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.

PATIENT DECLARATION 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, otherwise you may be charged for your treatment. Even if you have to pay for a service, you will always be provided with any immediately necessary or urgent treatment, regardless of advance payment. The information you give on this form will be used to assist in identifying your chargeable status, and may be shared, including with NHS secondary care organisations (e.g. hospitals) and NHS Digital, for the purposes of validation, invoicing and cost recovery. You may be contacted on behalf of the NHS to confirm any details you have provided.

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.

If you are visiting from another EEA country and do not hold a current EHIC (or Provisional Replacement Certificate (PRC))/S1, you may be billed for the cost of any treatment received outside of the GP practice, including at a hospital.

If yes, please enter details from your EHIC or PRC below:

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.

New Patient Questionnaire
Ethnic Origin
Next Of Kin
About You
Smoking
Alcohol

1 unit = half a pint of beer, 1 glass of wine or a pub measure of spirits

Family History

Is there any of the following in your family (father, mother, brother, sister) before the age of 60

Carers

If yes, ask the receptionist about Carers Support

Allergies
Online Access

Please ensure you have read the document which can be downloaded from the text above the form.


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.


Your Neighbourhood Professionals. Just a Click Away! Specsavers Opticians, Bearwood
Your Neighbourhood Professionals. Just a Click Away! Specsavers Opticians, Bearwood