If you live within our Practice Boundary and would like to register with the practice please use this form.

Once you have completed the form you will need to come into the practice with one proof of ID and one proof of address dated within 3 months to complete your registration. Please allow two working days for us to process your registration before visiting the surgery.

If you do not present yourself at the surgery with ID and or NHS number within 28 days of submitting the form it will be destroyed and the process will have to start over.

To register a child under 16 years of age with the practice please complete our Child New Patient Registration form (under 16).

If you are human, leave this field blank.

To register a child under 16 years of age with the practice please complete our Child New Patient Registration form (under 16)

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 at Birth: *

Male

Female

NHS Number:

If you were previously registered at another practice please contact the practice to obtain your NHS No.

Are you registering from a care home?

Yes

No

Is your care home residency:

Temporary

Permanent

Home Address: *

Postcode: *

Please check you live within our Practice Boundary before submitting this form.

Town and Country of birth: *

Do you identify as Transgender?

Yes

No

What gender do you identify as?

Male (including trans man)

Female (including trans woman)

Non-binary

Other

Please specify:

Previous Details

Previous address in UK: *

Please include postcode.

Name and address of previous GP: *

Electronic Prescription Service (EPS)

The Electronic Prescription Service (EPS) is a NHS service that allows us to send your prescription(s) directly to your chosen pharmacy. This paper-free prescription service means that you do not have to come into the surgery to collect your prescription.

Please request your prescriptions in the normal way through your surgery.

If you do not nominate a pharmacy then we will assign you to the pharmacy nearest to your home address - but this can be changed at any time.

Do you already have a nominated pharmacy?

Yes

No

Would you like to stay with your nominated pharmacy?

Yes

No

My chosen Pharmacy is: * Please select a Pharmacy... Boots, Halfhide Lane Brookfield Centre Boots, Waltham Cross Shopping Pavillion Boots, 694 Goffs Lane Cheshunt Chemist, 21 Cromwell Avenue Coyle Chemist, 147 High Street Cristal Chemist, 4 Lynton Parade Day Lewis Pharmacy, Vancouver Road Lex Pharmacy, Rosedale Way Medit-Shop, 25 High Road Niti Pharmacy, Unit 26 Waltham Cross Shopping Pavillion Punni Chemist, 49 High Street Salepick Ltd, 26 Station Road Swan Pharmacy, 5 Clayton Parade Whitefield Chemist, 76 High Street Lloyds Pharmacy, 1-4 Limes Court Boots Pharmacy, 4-6 Fawkon Walk Lloyds Pharmacy Inside Sainsbury's, Brewery Road Well Hoddesdon, 105 Rye Road Ware Cross Pharmacy, EN1 9FF Elgon Chemist, EN10 7HX Elgon Chemist, EN9 2JL Jade Pharmacy, EN10 7 HX Croft Chemist, EN10 6HT Village Pharmacy, SG12 8AQ Boots Pharmacy, EN8 0NN Boots Pharmacy, SG14 1BN Other

Pharmacy Name: *

Pharmacy Address: *

Pharmacy Postcode: *

If you are from abroad

Your first UK address where registered with a GP:

Date you came to live in the UK:

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

Contact Details

Home Phone Number:

Mobile Phone Number:

Work Phone Number:

Can we contact you by phone? *

Yes

No

Email Address: *

Can we contact you by email? *

Yes

No

Would you like to register for online services?

Yes

No

Registering for online services allows you to book and cancel appointments, order repeat prescriptions, changes your contact details and review your medications and known allergies

Status

Single

Married

Separated

Divorced

Widowed

Cohabitating

Disability

Do you consider yourself to have a disability?

Yes

No

Physical impairment (please specify)

Sensory impairment (please specify)

Learning disability/difficulty (please specify)

Mental Health condition (please specify)

Other (please specify)

Ethnicity

Please specify the ethnic group you consider you belong to:

Please select from the following... White British White Irish Other White Asian British Bangladeshi Indian Pakistani Other Asian Black British Black Caribbean Black African Other Black Asian and White Asian and Black Asian and Caribbean White African White Caribbean Chinese Japanese Middle Eastern Turkish I do not wish to state Other ethnic group

Do you speak English?

Yes

No

Do you read English?

Yes

No

First Language:

Emergency Contact

Full Name:

Relationship to you:

Phone Number:

Are they your Next of Kin?

Yes

No

Do you give us permission to discuss your medical records with them?

Yes

No

Please submit a signed document to this purpose as soon as possible. Your request will not be acted upon until the authority is received at the practice.

Allergies

Do you have any allergies?

Yes

No

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

Carers

Do you have a carer?

Yes

No

Are you a carer for someone?

Yes

No

Name of carer:

Phone Number:

Address:

Do you give us permission to discuss your medical record with your carer?

Yes

No

Please submit a signed document to this purpose as soon as possible. The above request will be added to your record but will not be acted upon until the authority is received at the practice.