New Patient Registration (for care home)

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.

To confirm your registration, we will require identification (this should be photographic, such as a passport or a Photo Driving Licence) which can be attached to this form.

New Patient Registration (for care home)

If you are human, leave this field blank.

Practice you want to register to: *

Please select... Horizon Healthcare St Thomas Road Surgery

Patient is going to be staying at care home for: *

15 days or less (temporary registration)

15 days or more (permanent registration)

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 assigned at birth: *

Male

Female

Indeterminate

Gender identity if different:

NHS Number: *

Town and Country of birth: *

Care Home Address: *

Postcode: *

Email Address: *

Any responses we send will go to this email address.

Home Phone Number:

Mobile Phone Number:

Can we contact you by text?

Yes

No

What date did the patient enter the care home?

Additional comments:

Ethnicity

Please specify the ethnic group you consider you belong to:

White British

White Irish

Black Caribbean

Black African

Black Caribbean and White

Black African and White

Indian

Pakistani

Bangladeshi

I do not wish to state

Other ethnic group

Please state:

Do you speak English?

Yes

No

First Language:

Allergies

Do you have any allergies?

Yes

No

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

Emergency Contact

Full Name:

Relationship to you:

Phone Number:

Are they your next of kin?

Yes

No

Previous Details

Previous address in UK:

Please include postcode.

Have you been registered at another surgery before? *

Yes

No

Name and address of previous GP:

NHS Number *

To find your NHS number you can contact your previous surgery and ask them for it. Alternatively it is also available on your prescriptions or any medical letters you may have received.

NHS Number

You can find this on your prescriptions or any medical letters you may have received.

If you are from abroad

Registering with the NHS 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 registered with the NHS 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

Name of carer:

Phone Number:

Address:

Nominate a Pharmacy

We will digitally send prescriptions to your chosen pharmacy: * Please select an option... Manor Pharmacy, 1 Burton Road, DE1 1TH Day – Night Pharmacy, 5 Wilson Street, DE1 1PG Manor Pharmacy, 99-101 St. Peter’s Street, DE1 2AB Dean and Smedley Ltd, 75 Prince Charles Avenue, DE22 4BG Boots Kingsway Retail Park, DE22 3FA Other I do not wish to nominate a pharmacy

Pharmacy Name: *

Pharmacy Address: *

Pharmacy Postcode: *