Registration Form

Please fill in the online form below to register at our practice

Registration Form

To register with our practice, ALL YOU NEED TO DO IS FILL IN THE FORM BELOW AND SUBMIT IT. Or you can print the forms and hand them in to reception or send them by post

Name*
First Last
Address*
Street Address Address Line 2 City County / State / Region ZIP / Postal Code Country
Date of Birth*

Day
Month
Year
Previous Address (if unchanged please duplicate same address)*
Street Address Address Line 2 City County / State / Region ZIP / Postal Code Country
Previous GP Surgery*
Please say name of Doctor (if known), address of surgery including postcode and tel no (if known)
If you have moved to the UK please let us know the date that you have moved to the UK and which country you were previously resident in.
Has you been diagnosed with any of the following medical conditions?*
- No medical conditions
- Diabetes on insulin
- Diabeties on oral medication or diet only
- Asthma
- COPD (Chronic Lung condition)
- Stroke
- Heart Condition
- Dementia
- Mental Health Condition
- Epilepsy
- Parkinsons
- Rheumatoid Arthritis
- Osteoarthritis
- High Blood pressure
- Cancer (on active treatment)
- Thyroid problems
- Other
Please tick all those that apply to you
Please list any allergies*
Please list any medications you are on. If possible include the dose you are on.*
If you are not on any medication write none.
Name of the GP Surgery and town, where your records are held currently*
Place of Birth*
Contact Telephone numbers.*

Please add all relevant tel nos
Upload a copy of a photo ID (REQUIRED)
Max. file size: 64 MB.
Passport or Driver's licence please. Ideally upload a photo straight away with this application or send it to us by email to portcullis.dutymanager@nhs.net. If you don't have either of these IDs, please fill in the form and call us. If you are registering a child a copy of their birth certificate or a parents ID may be acceptable.
OPTIONAL ADDITIONAL INFORMATION ABOUT YOURSELF
Please answer the questions below as fully as possible as it will help with your care.
Please let us know name and tel numbers of any Next of Kin
If you have an Email please add below
Do you currently work, please describe your occupation?
Please let us know if you are an Armed Forces Veteran
Regardless of when you left the military, please tell us that you’ve served in the UK Armed Forces. This will help our practice to better understand any military related health conditions that you may have and ensure that you are referred, where appropriate, to dedicated services for veterans. Our lead GP for veteran services is Dr Targett.
Sexual orientation and Gender Identity
If your GP is made aware of your sexual orientation and gender identity this can help identify your health care needs. Only you can decide if you would like to share with us what sexual identity best describes you. By asking this question we are trying to become more inclusive as a practice and allow patients to self-disclose this information, if you choose to and improve health outcomes as a result Sexual orientation is about who you’re attracted to and who you feel drawn to romantically, emotionally, and sexually. It’s different than gender identity. Gender identity isn’t about who you’re attracted to, but about how you identify yourself — male, female, transgender.
Do you currently have a signed Do not resusitate or Respect form?
Please write a description of what your respect form says
Please upload a copy of your DNAR/Respect form if you have one if possible
Max. file size: 64 MB.
Are you a smoker?
- YES (I smoke cigarettes, rollups or pipe)
- NO I have recently given up
- NO I am an ex-smoker >1 year
- NO never smoked
How tall are you?
How much do you weigh?
Has anyone in your family been diagnosed with any of the following medical conditions?
- No medical conditions in my family
- Diabetes on insulin
- Diabeties on oral medication or diet only
- Asthma
- COPD (Chronic Lung condition)
- Stroke
- Heart Condition
- Dementia
- Mental Health Condition
- Epilepsy
- Parkinsons
- Rheumatoid Arthritis
- Osteoarthritis
- High Blood pressure
- Cancer (on active treatment)
- Thyroid problems
- Other
For close family members (parents, siblings, grandparents, children) Please tick all those that apply to your family
How many sessions of vigorous activity have you taken in the last 4 weeks?

(1 session is 30 mins of vigorous activity)
How often do you have a drink that contains alcohol?
- Never
- Monthly
- Once a week
- 3-4 times per week
- 5+ times per week
How many units of alcohol do you have on a typical day drinking?
- 1-2
- 3-4
- 5-6
- 7-9
- 10+
How often do you have 6 or more units of alcohol on one occasion?
- Never
- Occasionally
- Monthly
- Weekly
- Daily or almost daily
Diet Options
- No special diet
- Low fat diet
- Vegetarian
- Gluten free diet
- Vegan
- Dairy free diet
Any additional information
Please describe below any additional information you would like to share with us.
Comments
This field is for validation purposes and should be left unchanged.

NEW PATIENTS: How do I register?

How can I book an appointment?

Advice on what to do in an emergency

How can I order a prescription?

Information about Services

How to Register for Online Access

Email for Advice, Help or an Appointment

How can I update my details?

How can I give feedback to improve services?

Accessible Information Standard

Portcullis Surgery is an Armed Forces Veteran friendly Accredited GP practice

Portcullis is an LGBT inclusive practice

Opening Times

Monday
08:30 until 20:00
6-8pm Pre-booked appointments only.Call 111 for advice OOH
Tuesday
08:30 until 20:00
6-8pm Pre-booked appointments only.Call 111 for advice OOH
Wednesday
08:30 until 20:00
6-8pm Pre-booked appointments only.Call 111 for advice OOH
Thursday
08:30 until 18:30
Call 111 for advice OOH
Friday
08:30 until 20:30
Open 1-2 Fridays a month. 6-8pm Pre-booked appointments only.Call 111 for advice OOH
Saturday
08:30 until 12:30
Open 1-2 Sat per month Pre-booked appointments only. Call 111 for advice OOH
Sunday
CLOSED
Call 111 for advice OOH

Useful Links

Portcullis Surgery

Registration Form