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.
Which parent has parental responsibilities?
Register as an organ donor?
For patients aged 15 and over:
Are you currently on any REGULAR medication?*
Are you able to administer your own medicine?*
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 (last 2 months) and may constitute a Bank Statement; Utility Bill or Tenancy Agreement.
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