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New patient registration

New Patient Registration
Are you currently registered with another surgery in the UK?

Patient’s Details

Title
Please use this date format: DD/MM/YYYY.
Gender
Any responses we send will go to this email address.
Can we contact you by text?
Can we contact you by email?
Do you have any speech or hearing impediment?

Ethnicity

Please specify the ethnic group you consider you belong to:
Do you speak English?
Do you read English?

Emergency Contact

Are they your next of kin?
Do you give us permission to discuss your medical records with them?

Allergies

Do you have any allergies?

Previous Details

Please include postcode.

Armed Forces

Have you ever served in the armed forces?
Is a member of your immediate family currently a member of the armed forces?

Carers

Do you have a carer?