Adult New Patient Registration

If you would like to register with the practice please use this form.

To register a new patient you will need to live within our practice boundary.

Eastfield New Patient Registration - Adult

Patient's Details

Title: *
Marital Status:
Please use this date format: DD/MM/YYYY.
Sex: *

If you are from abroad

Please use this date format: DD/MM/YYYY.
Please use this date format: DD/MM/YYYY.

Ethnicity

Please specify the ethnic group you consider you belong to: *

Can we contact you by text? *
Any responses we send will go to this email address.
Can we contact you by email? *
Preferred method of communication:
Do you require correspondence in any of the alternative formats:

Armed Forces/Veterans

Have you ever served in the Armed Forces?
Please use this date format: DD/MM/YYYY.
Please use this date format: DD/MM/YYYY.
Have you ever served on a merchant navy vessel operated to facilitate military operations?

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

Personal Information

Are you a healthcare worker?
Do you care for a chronically sick or disabled friend / relative?

Please provide details of the person you care for:

Please use the format DD/MM/YYYY.

Carers

Do you have a carer?
Please use the format DD/MM/YYYY.

Current Health

Do you have HIV, Hepatitis B or Hepatitis C?
Do you have any allergies?

Medication

Are you currently taking any prescribed medication?

Please make an appointment to discuss your medication with the Practice Pharmacist