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 State / Province / 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 State / Province / 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: 2 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.
Please let us know name and tel numbers of any Next of Kin
If you have an Email please add below
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: 2 MB.
Do you currently work, please describe your occupation?
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
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Comments
This field is for validation purposes and should be left unchanged.

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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