Patient Under Age of 18 Registration Form

If you live within our catchment area (marked below) and would like to register with us you can do so in person by asking reception for the registration form. Alternatively you can complete the form below and submit it online. 

Personal Details

Parent's Details

Mother's Details:

Father's Details:

Which parent has parental responsibilities?

Can you speak English?
Do you have a carer
Do you care for someone?
Do you have a Social Worker?

GP Details

Mandatory: Please indicate which chemist you would like us to send your prescriptions to (these will be sent electonically by computer)

Medical Details

Do you suffer from any of these medical conditions? Tick all that apply.

Register as an organ donor?

For patients aged 15 and over:

Are you...

Are you currently on any REGULAR medication?*

Are you able to administer your own medicine?*

Photo identification

In order to register we need to confirm your identity. Please upload a picture of a valid photo ID. This can be a passport of any nationality, a UK driving licence or birth certificate. 

Select Picture
Proof of address

In order to register we need to confirm that you live within our catchment area. Please upload Proof of address, this must be recent (last 2 months) and may constitute a Bank Statement; Utility Bill or Tenancy Agreement.

Select Picture

I consent to receive relevant email communication.*

I consent to receive relevant SMS communication.*

I understand that if I live outside home visiting area I will be unable to receive home visits*

Please complete required fields

Practice leaflet

When you join the practice you will receive a copy of the practice information leaflet which is also available for download here (PDF).