St Thomas Road Patient Registration

If you would like to register with St Thomas Road Surgery, 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.

Use this service to find your NHS number: www.nhs.uk/find-nhs-number

New Patient Registration

If you are human, leave this field blank.

Practice you want to register to: *

Please select... Horizon Healthcare St Thomas Road Surgery

Patient's Details

Title *

Mr

Mrs

Miss

Ms

Other

Please specify:

First Name(s) *

Surname: *

Previous Surnames:

Date of Birth: *

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

Gender assigned at birth: *

Male

Female

Indeterminate

Gender identity if different:

NHS Number:

If you do not know your NHS number please visit www.nhs.uk/find-nhs-number

Town and Country of birth: *

Home Address: *

Postcode: *

Email Address: *

Any responses we send will go to this email address.

Home Phone Number:

Mobile Phone Number:

Work Phone Number:

Is the patient under the age of 16? *

Yes

No

Patients under the age of 16 should complete the Child New Patient Registration form

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

Do you read 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:

Previous Details

Previous address in UK:

Please include postcode.

Name and address of previous GP:

Have you been registered at another surgery before? *

Yes

No

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 or you can visit www.nhs.uk/find-nhs-number.

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.