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.
Next of Kin:
Have you nominated someone to speak on your behalf (e.g. a person who has Power of Attorney)?
Opt out of being an organ donor?
For patients aged 15 and over:
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.
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 (lwithin the last 2 months) and may constitute a Bank Statement; Utility Bill or Tenancy Agreement.
In order to register any new patient under 5 years of age, please upload a copy of their immunisation record/history
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