New Patient Registration

If you are over the age of 16 and 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.

New Patient Registration - Adult (Ferguson)

About You

Please use this date format: DD/MM/YYYY
Gender *

Contact Information

Any responses we send will go to this email address.
Please select your preferred choice of contact:
Do you live in a residential home?
Do you live in a nursing home?
Would you describe yourself as homeless?


Please include postcode.

Service Families and Military Veterans

As a practice, we fully support the Armed Forces Covenant. We can only do this if we know our patients’ connections to the Armed Forces.

Please tick the below boxes that apply to you:

Asylum Seekers

Are you classed as an Asylum seeker?


Having information about patients’ ethnic groups would be helpful for the NHS so that it can plan and provide culturally appropriate and better services to meet patients’ needs.

If you do not wish to provide this information you do not have to do so.

Please indicate your ethnic origin

Preferred Title

Religious Affiliation

Country of Birth

Please use this date format: DD/MM/YYYY

Main Language

Do you speak English?
Do you need an interpreter?

Carer Status

Do you have a carer?
Is your carer a patient at the surgery?
Do you give consent to contact your carer about your care?
Are you yourself a carer?

Next of Kin

Contacting You

We will use your contact details to send reminders about appointments, reviews and other services which may be of benefit in your medical care.

Do you consent to the Surgery sending letters to your home address?
Do you consent to the Surgery sending text messages to your mobile?
Do you consent to the Surgery sending messages to you by email?
Do you consent to the Surgery leaving messages on your phone?

(We will not leave detailed messages on your phone,but may ask you to contact us or leave a simple message if we do not need to speak to you).

Are you interested in joining our Patient Participation Group (PPG)?

Summary Care Record (SCR)

If you decide to have an SCR, it will contain important information about any medicines you are taking, allergies you suffer from and any bad reactions to medicines that you have had it will also include basic information about your current diagnoses.

Giving healthcare staff access to this information can prevent mistakes being made when caring for you in an emergency or when your GP practice is closed.

Your Summary Care Record will also include your name, address, date of birth and your unique NHS Number to help identify you correctly.

If you and your GP decide to include more information it can be added, but only with your express permission.

For more information, visit

Please provide your Summary Care Record choice:

This will mean NHS Healthcare staff caring for you may not be aware of your current medications, any allergies or reactions to previous medication.

Local Shared Electronic Health Record

Many areas of the country have a local shared electronic health record too. Giving healthcare staff access to this information can prevent mistakes being made when caring for you in an emergency or when your GP practice is closed.

Are you happy for your record to be shared across organisations caring for you? (This is accessed by relevant staff for your direct care on a need-to-know basis only.)

Are you happy to be part of the local shared electronic health care record?

This will mean that NHS Healthcare staff may not be able to see important elements of your care history.

Electronic Prescribing Service (EPS)

The EPS allows prescribers – such as GPs and practice nurses to send prescriptions electronically to a dispenser (such as a pharmacy) of the patient’s choice. This makes the prescribing and dispensing process more efficient and convenient for patients and staff.

As a practice, we would encourage all patients to opt for electronic prescribing.

Please provide your Electronic Prescription Service choice:

Nominate a pharmacy:

Donation Wishes

If you live in England, Wales or Jersey, are not in a group excluded from opt out legislation and you have not registered an organ donation decision, it will be considered that you agree to be an organ donor. This is known as deemed consent.

If you do not want to donate your organs then you should register your decision to refuse to donate. Remember to speak to your family and loved ones about your decision.

To opt out, visit:

Do you have a donor card or are you on the organ donation register?
Have you opted out?
Do you donate blood?

NHS Blood Donor registration

If you would like to join the NHS Blood Donor Register as someone who may be contacted and would be prepared to donate blood, please visit their website on: or call direct on 03001232323

Resuscitation wishes and Power of Attorney

Do you have a DNACPR (Do not attempt CPR) form in place?

Please supply a copy for your medical notes to the surgery.

Does anybody hold Lasting Power of Attorney for Health and Welfare for you?

Please supply a copy for your medical notes to the surgery.

Any history of Domestic Violence?

Supplementary Questions

I am not ordinarily a resident in the UK

Ordinarily Resident

Anybody in England can register with a GP practice and receive free medical care from that practice.

However, if you are not ‘ordinarily resident’ in the UK you may have to pay for NHS treatment outside of the GP practice. Being ordinarily resident broadly means living lawfully in the UK on a properly settled basis for the time being. In most cases, nationals of countries outside the European Economic Area must also have the status of ‘indefinite leave to remain’ in the UK.

Some services, such as diagnostic tests of suspected infectious diseases and any treatment of those diseases are free of charge to all people, while some groups who are not ordinarily resident here are exempt from all treatment charges.

More information on ordinary residence, exemptions and paying for NHS services can be found in the Visitor and Migrant patient leaflet, available from your GP practice. Alternatively for more information go to

You may be asked to provide proof of entitlement in order to receive free NHS treatment outside of the GP practice, otherwise you may be charged for your treatment. Even if you have to pay for a service, you will always be provided with any immediately necessary or urgent treatment, regardless of advance payment.

The information you give on this form will be used to assist in identifying your chargeable status, and may be shared, including with NHS secondary care organisations (e.g. hospitals) and NHS Digital, for the purposes of validation, invoicing and cost recovery. You may be contacted on behalf of the NHS to confirm any details you have provided.

Please select one of the following statements:

I declare that the information I give on this form is correct and complete. I understand that if it is not correct, appropriate
action may be taken against me.

A parent/guardian should complete the form on behalf of a child under 16.

European Economic Area (EEA) Country

For a list of EEA countries visit:
Do you live in another EEA country, or have moved to the UK to study or retire, or live in the UK but work in another EEA member state?
Do you have a non-UK European Health Insurance Card (EHIC) or a Provisional Replacement Certificate (PRC) ?

If you are visiting from another EEA country and do not hold a current EHIC (or Provisional Replacement Certificate (PRC))/S1, you may be billed for the cost of any treatment received outside of the GP practice, including at a hospital.


Please enter the details from your EHIC or PRC below.

S1 Form

Do you have an S1 Form?
Please give your S1 form to the practice staff.

How will your EHIC/PRC/S1 data be used?

By using your EHIC or PRC for NHS treatment costs your EHIC or PRC data and GP appointment data will be shared with NHS secondary care (hospitals) and NHS Digital solely for the purposes of cost recovery. Your clinical data will not be shared in the cost recovery process.

Your EHIC, PRC or S1 information will be shared with The Department for Work and Pensions for the purpose of recovering your NHS costs from your home country.