New Patient Registration

To start the registration process with our practice you will be asked to fill in a registration form AND health questionnaire. You can complete these two forms by either calling into reception or completing them online - using the form below.

PLEASE NOTE - All fields are mandatory including your NHS number. You can obtain your NHS number through your existing GP. 

If you do not have a record of your NHS number or are new to the country, your online form will NOT be accepted. Please visit reception in person, in addition you will also be required to provide documentation to verify your identity and address. 

Anyone living within our Practice boundary is welcome to register with us. Prospective patients are asked to bring their medical card to the surgery if possible and will also be asked to complete and sign a patient registration form. All new patients joining our Practice will be offered a general health check with the Practice Nurse or Health Care Assistant.

PRACTICE AREA

The surgery provides general medical services for the geographical area of Coventry

To ensure that we can provide the appropriate standard of medical care, which includes home visits where necessary, we are only able to accept new patients from within this boundary area.

Please complete the form to register yourself with our surgery.
Any field marked with * is mandatory

Personal details

Please enter your NHS number if previously registered with NHS
We can register you with our surgery if you provide an official ID photo, e.g. a passport or drivers license. Simply upload from your library if you are on a mobile device, or as an image file from a computer. This image is kept safe and is only accessed by our surgery staff with the sole purpose to register you.
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Current address details

Contact details
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Previous GP details

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

Your previous address:

Provide the name and address of the previous Doctor while at that address:

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If you are from abroad

Check the box below if the address is the same as the previous tab:

 
If you are returning from the armed forces
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Medical history

Smoking
Do you smoke?*
How often do you have a drink containing alcohol?

How many units of alcohol do you drink on a typical day when you are drinking?

How often have you had 6 or more units if female, or 8 or more if male, on a single occasion in the last year?

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Medical history continued

Do you suffer with any of the following medical conditions?
Do you have any family history of the following medical conditions?

If you have checked any of the family history boxes above, please outline what relation has/had what condition below:

Do you require an interpreter?
Are you cared for by someone?
Do you care for someone else?
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Additional Information

NHS Organ Donor Register
I would like to join the NHS Blood Donor Register as someone who may be contacted and would be prepared to donate blood:
 
Have you given blood in the last 3 years?
Final details
Were you previously registered with another local practice?
Do you consent to us contacting you from time to time by email?*
Do you consent to us contacting you from time to time by text message?*

We have a patient participation group who meets with the practice on a regular basis. If you are interested in joining the group please check the box below and we will get in touch:

 
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