New Patient Registration

After you’ve completed the form

It will take us 5 working days to process your request. Our staff may contact you if they need to clarify any information.

Please note that if you move outside our practice boundary, we are unable to accept you as a patient/ keep you on our list. ​

Practice Area:

  • Ampthill
  • Clophill
  • Eversholt
  • Flitton
  • Flitwick
  • Greenfield
  • Harlington
  • Haynes West End ( West of A6 only)
  • Houghton Conquest
  • Liddlington
  • Maulden
  • Millbrook
  • Pulloxhill
  • Steppingley
  • Tingrith
  • Westoning

Patient's Details

Please use this date format: DD/MM/YYYY.

Please complete at least one phone number.

Any responses we send will go to this email address.

Please help us trace your previous medical records by providing the following information

e.g. Previously / currently homeless or Newborn baby
Please include postcode.

If you are from abroad

Registering for the first time in the UK

Please use this date format: DD/MM/YYYY.

If you are returning from abroad

Previously been a resident in the UK

Please use this date format: DD/MM/YYYY.
Please use this date format: DD/MM/YYYY.

If you are returning from the armed forces

Supplementary Questions

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 www.nhs.uk/visitingengland.

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.

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: www.gov.uk/eu-eea

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.

EHIC/PRC

Please enter the details from your EHIC or PRC below.

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.

NHS Organ Donor registration

If you would like to join the NHS Organ Donation Register please visit their website on: www.organdonation.nhs.uk/consent.do

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: www.blood.co.uk or call direct on 03001232323

Patient Details

Next of Kin

If you need your next of kin to be able to discuss your medical records then please contact the surgery for advice on how to arrange this.

Nationality

If you need a translation service for a consultation then please let us know when you book your appointment.

Religion

Summary Care Record

The NHS Summary Care Record is an electronic record of important information about your health. It will be available to health care staff providing your NHS care.

You will also need to complete the Summary Care Record Opt Out form.

Sharing Records

Care.Data

Care.Data is the sharing of medical records for research at national level.

Carers

If you need your carer to be able to discuss your medical records then please contact the surgery for advice on how to arrange this.

Power of Attorney

Medical History

Family Medical History

Smoking

Exercise

Under 5

The practice will be forwarding the following information on to the relevant Health Visitors attached to the area. Please confirm you are aware of this by signing and dating below.

5 to 16 year's old

The practice will be forwarding the following information on to the School Nursing team. This has been requested by the School Nursing team and is as a result of national recommendations (arising from the Laming enquiry into the death of Victoria Clumbie). School Nurses have a duty to ensure that they are aware of all school aged children who are registered with our Practice, attending school in our area/or living within our boundaries.

Please confirm you are aware of this by signing and dating below.

Names of Parent(s) or Guardian(s) - To be shared

Child's Information - To be shared

Alcohol Consumption

Please only complete this alcohol questionnaire if you are registering someone aged 16+.

This is one unit of alcohol:

And each one of these, is more than one unit:

This is your total score from the first part of the Alcohol Consumption.