Get Patient Application Form

Completing the Patient Application Form online is an essential step for new patients to register with the medical practice. This guide provides you with a comprehensive overview of each section of the form, ensuring you have the necessary information to fill it out accurately and efficiently.

Follow the steps to complete the form successfully.

1. Click ‘Get Form’ button to access the Patient Application Form and open it in your browser.
2. Begin by entering your surname in the designated field. If applicable, include your maiden name.
3. Indicate your marital status by selecting from the options: Married, Single, Divorced, or Widowed.
4. Fill in your forenames, date of birth, and usually known name in the respective fields.
5. Input your home telephone number, mobile number, and work telephone number. If you prefer not to receive appointment text reminders, sign in the provided space.
6. Provide your address and postcode, and fill in details for any private health insurer, including your policy number.
7. If you are currently attending school, please indicate the name of the school.
8. Fill in your social insurance number, ethnic origin, and language preferences.
9. Answer whether you are a carer or if you have a carer, and provide the name of the carer if applicable.
10. Enter your next of kin's details, including their name, relationship, address, and telephone numbers.
11. Provide the names and details (surname, forename(s), and date of birth) for your children.
12. Fill in your current occupation, employer’s name, and contact information.
13. If applicable, fill in the details of your previous doctor, including their name and contact information.
14. Specify which doctor you would like to be registered with, if you have a preference.
15. If you have moved to the area recently, provide your date of arrival, intended length of stay, and your previous address.
16. Indicate how you heard about the practice from the provided options.
17. Complete the ethnicity section by checking the appropriate boxes.
18. Answer the health-related questions regarding medical history, smoking, alcohol consumption, and exercise.
19. For female patients, complete the specific health questions regarding pregnancy and gynaecological history.
20. Provide details of immunizations or vaccinations you have received.
21. Fill in any current medications you are taking, both over-the-counter and prescription.
22. Provide additional health information that may be useful for your doctor.
23. Review all your input for accuracy, then save your changes, and choose to download, print, or share the form.

Complete your Patient Application Form online to ensure a smooth registration process.