Victoria Road Surgery

New Patient Registration – Adult

Everyone is welcome in general practice. You do not need to provide proof of ID, address, immigration status or an NHS number in order to receive care or see a GP.

To access our services, you will need to be registered as a patient with us.

The registration process is quick and easy. Fill out the form and our admin team will process your registration.

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

  • Patient Details
  • Previous information
  • Additional info
  • Communication
  • Patient Declaration

Patient Details



First Name(s)

Date of Birth

Place of Birth

NHS Number (if known)




Main or 1st language spoken/understood

Proof of address - Please provide a copy of a document, not older than 3 months, that provides a proof of address.

Max. size: 2.0 MB

Contact Information


Telephone Number

Mobile Number


Preferred choice of contact

Do you live in a residential home?

Do you live in a nursing home?

Would you describe yourself as homeless?

What is your occupation?

Previous details in UK

Your previous address & postcode in UK

Name of previous GP

Address of previous GP practice

If you are from abroad

Your first UK address where registered with a GP

If previously a resident in UK, date of leaving

Date you first came to live in UK

Were you ever registered with an Armed Forces GP

Please indicate if you have served in the UK Armed Forces and/or been registered with a Ministry of Defence GP in the UK or overseas:

Are you classed as an Asylum seeker?

If so, please indicate your country of origin

Address & postcode before enlisting

Service or Personal number:

Enlistment date

Discharge date (if applicable)

Footnote: These questions are optional and your answers will not affect your entitlement to register or receive services from the NHS but may improve access to some NHS priority and service charities services.


What is your height

What is your weight

If you would like advice on managing a healthy weight please contact

Carer Information

Do you have a Carer?

If yes, are they registered at this practice?

Carer name:

Telephone number:

Do you consent for your carer to be informed about your medical care?

Are you a Carer? (Only if you are a registered Carer)

If yes, do you look after someone who is a patient at this practice

If yes, what is their name?

Are they a

Please upload a photo ID

Max. size: 2.0 MB

Next of kin


First Name



Emergency contact Information (for next of kin)



Please tell us about your smoking habits, alcohol consumption, and exercises

Do you smoke?

If yes, how many do you smoke a day?

Would you like advice on quitting?

Are you an ex-smoker?

Do you drink alcohol?

If yes, how much alcohol do you drink in a week (Units)?

Do you exercise?

If yes, how often do you exercise? (No. times per week and type(s) of exercise)

Medical Background

Are there any serious disease that affect your parents, brothers or sisters ( tick all that apply)

Any other important family illness?

Please detail below any specific needs you have so that practice can ensure they are identified and accommodated by taking the appropriate action.

Are you allergic to any medicines?

If yes, please specify

Do you have any other allergies?

List any other allergies you have (pollen, animal hair or certain foods)

Please select any Sensory Impairment you have.

Are you an Assistance Dog user?

Please state any physical disabilities you have.

Please state any mental disabilities you have.

Please state any requirements you have to be able to access the practice premises.

For female patients only

Are you currently pregnant?

If yes, please ensure you are under the care of a midwife. If you’re not currently under the care of a midwife please speak to reception regarding this.

Which method of contraception (if any) are you using at present?

Do you currently have long acting reversible contraception in place? (Implant/Coil)

Have you had a cervical smear test?

If yes, when was this fitted? (dd/mm/yy)

Have you had a hysterectomy?

Do you still have your ovaries?

Communication needs

We would like to get better at communicating with our patients. We want to make sure that you can read and understand the information we send you. If you find it hard to read our letters or if you need someone to support you at appointments, please let us know. We want to know if you need information in braille, large print or easy read. We want to know if you need an interpreter for your appointments.

Do you have any communication needs?

What type of communication needs?

Do you need a format other than standard print?

Do you have any special communication requirements?

Spoken language

English speaker

Spoken Language:

Interpreter needed:

If yes what language

Local Shared Electronic Health Record

Many areas of the country have a local shared electronic health record too. Giving healthcare staff access to this information can prevent mistakes being made when caring for you in an emergency or when your GP practice is closed. Are you happy for your record to be shared across organisations caring for you? (this is accessed by relevant staff for your direct care on a need-to-know basis only)

Are you happy to be part of the local shared electronic health care record? (if you select no, you need to be aware that NHS Healthcare staff may not be able to see important elements of your care history

Electronic Prescribing Service (EPS)

The EPS allows prescribers – such as GPs and practice nurses to send prescriptions electronically to a dispenser (such as a pharmacy) of the patient’s choice. This makes the prescribing and dispensing process more efficient and convenient for patients and staff. As a practice, we would encourage all patients to opt for electronic prescribing.

EPS consent

Please give the name and address of your preferred pharmacy

Alternatively, you can collect it from the surgery

Donation wishes

If you live in England, Wales or Jersey, are not in a group excluded from opt out legislation and you have not registered an organ donation decision, it will be considered that you agree to be an organ donor. This is known as deemed consent. If you do not want to donate your organs then you should register your decision to refuse to donate. Remember to speak to your family and loved ones about your decision. To opt out,Visit

Do you have a donor card or are you on the organ donation register?

Have you opted out?

Do you donate blood?

Resuscitation wishes and Power of Attorney

Do you have a DNACPR (Do not attempt CPR) form in place?

If YES to either of the above questions, please supply details of who holds this and where (and supply a copy for your medical notes).


Summary Care Record
If you decide to have a SCR, it will contain important information about any medicines you are taking, allergies you suffer from and any bad reactions to medicines that you have had it will also include basic information about your current diagnoses. Giving healthcare staff access to this information can prevent mistakes being made when caring for you in an emergency or when your GP practice is closed. Your Summary Care Record will also include your name, address, date of birth and your unique NHS Number to help identify you correctly. If you and your GP decide to include more information it can be added, but only with your express permission. Click here for more information.

I wish to opt out of SCR

Sharing Out - Does the patient consent to the sharing of data recorded here with any other organisations that may care for the patient?

Sharing In - Does the patient consent to the viewing of data by this organisation that is recorded at other care services?

Patients Summary Care Record Consent Preference:

This practice uses a text messaging service to remind patients of appointments and remind patients when they are due for a review. If you provide a mobile number when registering, you will automatically be opted in to receive text messages. If you wish to opt out, please click the checkbox.

Please select one or more preferred method of contact

I declare that the information provided on this form is correct to the best of my knowledge

I consent to being contacted via the details given above. I agree to the privacy policy

To view our privacy policy, click here