New Patients - The Green Medical Centre

We are pleased to accept registration requests from patients who are living within our catchment area.

Catchment Area

If you reside within our catchment area, please complete the relevant form below—one for adults and one for children under 5. Kindly allow up to 2 weeks before contacting us for an update on your registration.

New Patient Registration Form – Adults

Registration Form for new patients

Personal Details

Title (Mr./Mrs./Miss/Master/Mx/Other)

Name

First Last

Name

Middle Optional

NHS Number Optional

Date of Birth

DD slash MM slash YYYY

Gender

Female

Male

Prefer not to say

Mobile

Home Telephone Optional

Work Optional

Can we contact you by the options below?

Phone

ID

We request proof of identity and address to verify your eligibility for registration and ensure you reside within our service area. This helps us provide accurate and efficient care.find your medical records or transfer them from your current GP. Acceptable forms of ID include a passport, driver’s license, birth certificate, or biometric residence permit. For proof of address, we accept a utility bill or bank statement dated within the last 3 months, a council tax bill, tenancy agreement, or mortgage statement.

Please upload ID

Max. file size: 50 MB.

Please upload Proof of Address

Max. file size: 50 MB.

Address

Providing your address helps us confirm that you reside within our catchment area.

Address

Street Address Address Line 2 City County / State / Region ZIP / Postal Code Country

Are you registering at a doctor's surgery in England for the first time?

Yes

Previous Address in the UK

Street Address Address Line 2 City County / State / Region ZIP / Postal Code Country

Name of previous GP practice while at the address

Address of previous GP practice

Street Address Address Line 2 City County / State / Region ZIP / Postal Code Country

Have you recently relocated to the UK from another country?

Yes

Your first UK address where registered with a GP

Street Address Address Line 2 City County / State / Region ZIP / Postal Code Country

If previously resident in the UK, date of leaving Optional

DD dash MM dash YYYY

Date you first came to live in the UK Optional

DD slash MM slash YYYY

Please indicate if you have served in the UK Armed Forces and/or been registered with a Ministry of Defence GP in the UK or overseas

Regular Optional

Reservist Optional

Veteran Optional

Family Member (Spouse, Civil Partner, Service Child) Optional

Consent to Summary Care Record

Do you consent to the inclusion of your information in the Summary Care Record, which allows healthcare professionals to access essential details about your health when needed?

Yes

Online Access

The Green Medical Centre offers online service and all new patients will be registered for these. The choice to activate and use the service will remain with the patient once registered on the system. However, email and mobile number is required.

Online Access Options

Booking appointments

Requesting repeat medications

Accessing medical records

I wish to have access to my medical records and I agree with the statements below (please tick the following)

I will be responsible for the security of the information that I see or download

If I choose to share my information with anyone else, this is at my own risk

I will contact the Practice as soon as possible if I suspect that my account has been accessed by someone without my agreement

If I see information in my record that is not about me or is inaccurate, I will contact the Practice as soon as possible

Marital Status

Single

Married

Divorced

Widowed

Separated

Domestic Partnership

Occupation

Military veteran

Yes

Ethnicity and Language

We are asking for this information solely to help us provide better care for you and your community.

Country of Birth

Ethnic Origin

White British

Irish

White and Black Caribbean

White and Black African

White and Asian

Black British

Caribbean

African

Asian British

Asian Indian

Asian Pakistani

Asian Bangladesh

Chinese

Other (please specify) Optional

What is your first language? Optional

Emergency Contact and Next of kin

Name of Emergency Contact

First Last

Name

Middle Optional

Relationship

Address

Street Address Address Line 2 City County / State / Region ZIP / Postal Code Country

Phone

Is your Emergency Contact your Next of Kin?

Yes

Name of Next of Kin

First Optional Last Optional

Name

Middle Optional

Reationship Optional

Phone Optional

Consent

I consent to allowing my next of kin to discuss my medical records. Optional

Personal Health History

If your BMI is over 30, we encourage you to contact the surgery for a weight management referral. You can also visit our ‘Keep Fit’ page for helpful advice and resources.

Weight Optional

Height Optional

Waist Measurement Optional

Alcohol

How often do you have alcohol?

How many alcoholic drinks do you have a day when you are drinking?

How often do you have 6 or more standard drinks on one occasion?

Your score ( Please add your score from the previous 3 questions and type in your total)

Tobacco

Do you use tobacco?

Yes

Do you vape?

Yes

Please select the type of tobacco products you use from the options below

Cigarettes

Roll own/use filter

Pipe

Cigars

Vape

Number of years smoking/vaping

Number smoked/vaped each day

Please select the option that best describes your smoking history

Never smoked tobacco

Ex-smoker

Please enter the year you quit

We advise you stop smoking to maintain good health. Contact the surgery for advice or speak with one of our practice nurses about smoking cessation and what they can do to help.

Exercise & Diet

Exercise Grading

inactive

moderately inactive

moderately active

active

If you are over the age of 18 years old and your BMI is over 31, please tick the box below if you would like to be referred to a weight management program

Yes Optional

No Optional

Carer

Do you have a carer?

Yes Optional

No Optional

Are you a registered carer for someone with a chronic disease or disability?

Yes Optional

No Optional

Please provide the name and address of the person who cares for you or whom you are caring for in the spaces below

Name

First Optional Middle Optional Last Optional

Address

Street Address Optional Address Line 2 Optional City Optional County / State / Region Optional ZIP / Postal Code Optional Country Optional

Personal Safety

Do you live alone?

Yes Optional

No Optional

Do you have vision or hearing loss?

Yes

Do you have any information or communication needs?

Yes

Do you use sign language?

Yes

Sight

Good

Poor

Registered blind

Hearing

Good

Poor

Partially Deaf

Deaf

Will you need an interpreter when seeing a clinician?

Yes

If you selected yes for the previous question, please specify Optional