New Patient Registration

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.

Child Registration

If you would like to register a child, please use our U13 Registration Form. 

New Patient Registration - Sheerwater

New Patient Registration - Sheerwater

About You

Please use date format DD/MM/YYYY

Ethnicity

Please select:

Carers

Are you a carer?

Please register as a carer using our Register a Carer form.

Making Information Accessible

If you would like us to record your communication needs on your medical record, please indicate below:

Previous Details

Please include postcode.

If you are from abroad

Registering with the NHS for the first time in the UK
Please use format DD/MM/YYYY

If you are returning from abroad

Previously been registered with the NHS in the UK
Please use format DD/MM/YYYY
Please use format DD/MM/YYYY.

Your Health Status

Smoking Status: *
Please use date format DD/MM/YYYY
Would you like to be referred to the Quit 51 smoking cessation service?

Alcohol

This is one unit of alcohol:

Amount of different types of drink representing one unit of alcohol

And each one of these, is more than one unit:

Amount of different types of drink representing more than one unit of alcoholAmount of different types of drink representing more than one unit of alcohol
How often do you have a drink that contains alcohol? *
How many alcoholic drinks do you have on a typical day when you are drinking? *
How often do you have 6 or more standard drinks on one occasion? *

Alergies/Intolerances

Medications and Prescriptions

Sheerwater Health Centre is an electronic prescribing practice and we are phasing out paper prescriptions where possible. Please nominate the pharmacy where you would like to collect your prescriptions and we will send them there electronically.

Family History

Please indicate if either of your parents, a sibling or a child has been affected by:

Health Questionnaire

If you have been registered with an NHS GP in England previously, we should receive your medical records electronically – please skip the questionnaire.

Cancer

Have you had Cancer?
Are you receiving treatment?

Heart or Circulatory Problems

Have you had/Do you have:

Lung or Respiratory Problems

Have you had/Do you have:

Gastro-Intestinal Problems (Stomach & Gut)

Have you had/Do you have:

Gastro-Urinary Problems

Do you have/Have you had:

Epilepsy

Do you have Epilepsy?
Have you been fit free for over 12 months?

Diabetes

Which of the following are used to control your diabetes?

Bone & Joint Problems

Hip Replacement
Knee Replacement

Mental Health

Do you have/Have you had:

Skin Problems

Do you have/Have you had:

Other Conditions

Do you have/Have you had:

For Women Only

Please use date format DD/MM/YYYY
Result of Last Cervical Smear:

Application for Access to Online Services

I wish to have access to the following online services:
Please tick the following statements to confirm your agreement: *

Consent for Someone Else to Act on Your Behalf

We are unable to discuss any aspect of your care or give your prescriptions to anyone other than you unless we have your express permission. If you would like to give consent for a family member, friend or carer to act on your behalf please complete the following:

I give consent to the following person:

To:

Consent for Text Communication:

At Sheerwater Health Centre, we use texts to keep you informed about your appointments and to send related healthcare messages.

If you have provided a mobile phone number you will be automatically enrolled for text messages about your direct care such as appointment reminders.

Please be aware that if you opt-out, you will not receive appointment reminders.

Summary Care Record

An electronic Summary Care Record is automatically created for you when you register. It contains brief health information such as your medications and allergies and can be viewed by clinicians who are treating you in other settings in England, such as A&E, Ambulance Services, other GP surgeries and out of hours services.

National Data Opt Out (Sharing of your personal information for purposes other than your own direct care)

NHS Digital collects health information from GP records, hospitals and other healthcare providers for planning and research purposes - sometimes this data includes information that could identify you. You are entitled to opt-out of your data being used in this way. Making this choice won’t affect the care you receive in any way.

You can opt-out online on the NHS Choices website www.nhs.uk from 25th May 2018. NHS Digital will be providing a non-digital alternative for patients who can’t or don’t want to use an online system.

The National Data Opt-out replaces the previous Type 2 opt-outs which patients registered with their GP.

GPDR ( General Data Protection Regulations May 2018)

How we use your information

  • We collect and hold data about you for the purpose of providing safe and effective healthcare
  • Your information may be shared with our partner organisations to audit services and help provide you with better care
  • Information sharing is subject to strict agreements on how it is used
  • If you are happy with how we use your information you do not need to do anything
  • If you do not want your information to be used for purpose beyond providing your care please let us know so we can code your record appropriately
  • You can object to sharing information with other health care providers but if this limits your treatment options we will tell you
  • Our guiding principle is that we are holding your information in the strictest confidence
  • We will only share your information outside of our partner organisations with your consent – unless the health and safety of others is at risk, the law requires it, or it is required to carry out a statutory function