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WHO CAN REGISTER

If you are ordinarily resident in the UK and live within our Practice area:

We accept new patients who live in our practice area as fully registered patients. Our practice area is Southam town and surrounding villages. Please fill in the form below to register as a patient.

If you are ordinarily resident in the UK but live outside our practice area, we can still accept you as an 'Out of Area Patient' but this means we will not be able to visit you if you need a home visit. More details are available by clicking on Out of Area Registration - GP Choice. Please fill in the form below to register as an 'Out of Area' patient.

Please click here to check whether you are in our practice area.

If you are not ordinarily resident in the UK you can still register as a patient but you will need to come into the surgery to do so.

 

FILLING IN THIS FORM

Please provide as much information as you can and ensure that you complete all questions marked as 'mandatory'.

You will receive a confirmation reference once your form has been successfully submitted. If you do not receive this, please check that you have completed all mandatory fields and then re-submit your form.

Successfully submitted forms will be processed within 48 hours. We will only contact you if there is a problem with your registration.

Please contact us if you would like to make an appointment to see the practice nurse (or doctor if you are on regular medication) for a new patient health check. This will ensure that our records are accurate and all routine checks to promote your health and well-being (such as blood pressure/smear tests/mammograms) are up-to-date.

 

1Personal Details

please specify
please provide your date of birth in the format dd/mm/yyyy
if you know your NHS number, please provide it

2Please help us trace your medical records

3If you are from Abroad

4If you are returning from the Armed Forces

5If Registering a Child under 5

6If you need your doctor to dispense medicines and appliances

7NHS Organ Donor Registration

8NHS Blood Donor Registration

9Confirm

10New Patient Questionnaire

Please tick only one
Please choose only one option
If you tick 'YES', please give details below

11Other details - Carers and Military Veterans

eg son, wife, partner etc

12Emergency Contacts

Optional, but please give title, forename and surname if you want to give a contact
please complete if you have named someone as a contact
eg son, wife, partner etc
please complete if you have named someone as a contact

13Current Medication. If you are taking medication please make an appointment to see the doctor before you next need it.

Please give name and town of preferred pharmacy. Please type SURGERY if you prefer to collect from the surgery.
eg son, wife, partner etc

14Please only answer if you are 16 or over

15Family History

Please say who and what type

16Anything Else

Please type NIL if you do not have any medical conditions

17Once you are registered with us you can book appointments and order prescriptions online. Please bring some photo ID to reception and ask for your 'registration letter'. You can visit the 'Do it Online' page on the website for more info.

18Summary Care Record

The NHS Summary Care Record is an electronic record of important information about your health. It will be given to health care staff providing your NHS care and includes information such as current medication, allergies and adverse reactions to medicines you have had.

If you chose, you can also opt to include additional information about your illnesses, health problems, operations and vaccinations you have had in the past and your preferences as to where and how you receive care.

19NHS Digital Data Sharing

NHS Digital (formerly the Health and Social Care Information Centre) collects information about the care you received from your GP and other healthcare providers with the purpose of aiding research and improving services.

If you do NOT wish to have your data extracted by NHS Digitial you can opt out by visiting www.nhs.uk/your-nhs-data-matters or ask a receptionist for details on how you can opt out by post.

20For out of area patients only


Privacy Protection

Information submitted through secure forms is used only for the purposes of processing your request. We may be in touch with you in relation to the information submitted.

All Information submitted through secure forms is secured with a private key known only to the GP practice and is accessed over a secure connection by nominated Practice staff. Our practice has a strict confidentiality policy.

This information is not shared with any third party organisations.

This information is retained for up to 28 days.

Learn more about our Privacy Policy and Terms of Use. Should you have any concerns about sending your personal details using the web, please use one of the alternative methods offered by our organisation.


© St Wulfstan Surgery - Outstanding CQC 5 Star NHSChoices 2018
Northfield Road, Southam, Warks, CV47 0FG
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