Re-registration as a Patient

Welcome back. The registration process for returning patients is quick and easy. Simply fill out the form below.

Please help us trace your previous medical records by providing the following information

  • Patient Details
  • Previous information
  • Additional info
  • Communication
  • Patient Declaration


Which practice were you previously registered to?

Which Practice would you like to register for?

Patient Details



First Name(s)

Date of Birth

Previous Surname(s)

NHS Number (if known)





Contact Number

Alternative Number


Previous details in UK

Your previous address & postcode in UK

Name of previous GP

Address of previous GP practice

If you are from abroad

Your first UK address where registered with a GP

If previously a resident in UK, date of leaving

Date you first came to live in UK

Were you ever registered with an Armed Forces GP

Please indicate if you have served in the UK Armed Forces and/or been registered with a Ministry of Defence GP in the UK or overseas:

Address & postcode before enlisting

Service or Personnel number:

Enlistment date

Discharge date (if applicable)

Footnote: 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.

Donor Registration

NHS Organ Donor registration

I want to register my details on the NHS Organ Donor Register as someone whose organs/tissue may be used for transplantation after my death. Please tick the boxes that apply.

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

NHS Blood Donor registration

Carer Information (not needed for children)

Do you have a Carer?

If yes, are they registered at this practice?

Carer name:

Telephone number:

Do you consent for your carer to be informed about your medical care?

Are you a Carer? (Only if you are a registered Carer)

If yes, do you look after someone who is a patient at this practice

If yes, what is their name?

Are they a

Please tell us about your smoking habits (not needed for children)

Do you smoke?

If yes, how many do you smoke a day?

Would you like advice on quitting?

Are you an ex-smoker?

Cervical Screening (Women only)

Have you had a Cervical Smear

Please state where, when and the result

Please ask the surgery to fill in a disclaimer form.


Are you allergic to any medicines?

If yes, please specify

Do you have any other allergies?

List any other allergies you have (pollen, animal hair or certain foods)

Communication needs

We would like to get better at communicating with our patients. We want to make sure that you can read and understand the information we send you. If you find it hard to read our letters or if you need someone to support you at appointments, please let us know. We want to know if you need information in braille, large print or easy read. We want to know if you need an interpreter for your appointments.

Do you have any communication needs?

What type of communication needs?

Do you need a format other than standard print?

Do you have any special communication requirements?

Spoken language

English speaker

Spoken Language:

Interpreter needed:

If yes what language

Nominated Pharmacy

We have electronic prescribing functionality, this will allow us to send your prescription electronically to your preferred choice of pharmacy, and will also save you time in collecting your prescription from the surgery. Your Nominated pharmacy at Lordswood will be: Knights Pharmacy (next door to the surgery) Your Nominated pharmacy at Selcroft will be: Selcroft Pharmacy (next door to the surgery) Your Nominated pharmacy at Quinton Family will be: Rajja Pharmacy (5 Dwellings Lane)

If you would like to use another Pharmacy, please give the name and address:

Alternatively, you can collect it from the surgery


Are you happy for authorised healthcare staff to view your medical record when you recieve direct patient care?

For further information, please visit the Your Care Connected website

Please select one or more preferred method of contact

I declare that the information provided on this form is correct to the best of my knowledge

I consent to being contacted via the details given above. I agree to the privacy policy

To view our privacy policy, click here