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New patient registration

New Patient Registration – EMIS Template

Please complete a New Patient Registration form for each member of the family that you wish to register including children.

The inclusion service is for people experiencing homelessness, sofa surfing and/or in temporary accommodation – not students.

Have you been registered with this surgery previously?

Patient Details

Title:
Please use date format: DD/MM/YYYY
Gender:
Religion:
Marital status:

Ethnicity

Please select one option that best describes your ethnic group:
Asian or Asian British:
Black, Black British, Caribbean or African:
Mixed or multiple ethnic groups:
White:
Other ethnic group:

If you are from abroad

Registering with the NHS for the first time in the UK
Please use date format: DD/MM/YYYY
Do you require an interpreter?
Do you speak English?
Do you read English?
Do you require any additional support?

Address and contact details

Any responses we send will go to this email address.
Preferred communication method:
Do you consent to the practice contacting you by telephone?
Can we contact you by text?
Can we contact you by email?
Which of the following best describes your gender?
Is your gender identity the same gender you were registered as at birth?
Which of the following best describes how you think of yourself?
Preferred name