Online Registration

Patient details
Title*
Date of Birth*
DD slash MM slash YYYY
Gender*
NHS Number
First Names*
Birth Town*
Surname*
Birth Country*
Current Address and Postcode*
Telephone*
Mobile*
Email Address*
Please help us trace your previous medical records by providing the following information
Have you previously been registered with an NHS GP in UK?*
- Yes
- No
Name of Previous GP*
Address of Previous GP*
Your Previous Address
This is usually the address when you were last registered with a GP
Your first UK address*
Date you first came to UK
DD slash MM slash YYYY
Are you returning from the Armed Forces?*
- Yes
- No
Please indicate if you have ever served in the UK Armed Forces and/or been registered with a Ministry of Defence GP in the UK or overseas*
- Regular
- Reservist
- Family Member
Address and Postcode before enlisting*
Service or Personnel Number*
Enlistment date*
If you need a doctor to dispense medicines and appliances
Please note: Not all doctors are authorised to dispense medicines
Nearest Chemist
- I live more than 1 mile in a straight line from the nearest chemist
Chemist Difficulty
- I would have serious difficulty in getting them from a chemist
Signatures
Signatures*
- Patient's signature
- Signature on behalf of patient
Consent
I agree for the Practice to contact me using the details provided above.
Electronic Signature (Type your full name here)*

By completing the section above, I hereby sign this form electronically
NHS Organ Donor Registration
Would you like to join the NHS Organ Donor Register?*
- Yes
- No
- Already on it
I want to register my details on the NHS Organ Donor Register as someone whose organs/tissue may be used for transplantation after my death.*
- Any of my organs and tissue
- Kidneys
- Heart
- Liver
- Corneas
- Lungs
- Pancreas
NHS Blood Donor Registration
Would you like to join the NHS Blood Donor Register?*
- Yes
- No
- Already on it
Tick here if you have given blood in the last 3 years
- I have given blood in the last 3 years
My preferred address for donation is:
Phone
This field is for validation purposes and should be left unchanged.

Please note that if you have never been registered on the NHS in the UK, you must complete all sections of the registration form.

Physio FIrst

Order your Prescriptions

Join our Patient Participation Group

Friends & Family Test

Covid-19 immunisation

PLEASE DO NOT TELEPHONE THE SURGERY TO ASK ABOUT YOUR COVID VACCINATION

FIRST DOSE

ALL PATIENTS AGED 18 TO 49 YEARS WILL BE CONTACTED ON OUR BEHALF BY ESSEX HOUSE TO BOOK THEIR VACCINATION WITH THEM

IF YOU ARE OUTSIDE THIS AGE BRACKET AND HAVE NOT RECEIVED YOUR FIRST DOSE PLEASE TELEPHONE 119

SECOND DOSE

IF YOU ARE AGED 50+AND HAVE NOT HAD YOUR SECOND COVID VACCINATION PLEASE TELEPHONE THE SURGERY OR 119

General Practice data extraction for planning and research Opt out information

NHS Digital has issued a Data Provision Notice for Planning and Research. This means this Practice is required to share your information with them unless you tell us not to. h.To opt out from please visit https://digital.nhs.uk/data-and-information/data-collections-and-data-sets/data-collections/general-practice-data-for-planning-and-research.

You can also opt out of the National Data extraction, formerly Type 2 Opt out. This would prevent your data, which NHSE already hold, from being used for research. To opt out please visit https://www.nhs.uk/your-nhs-data-matters/

Data Provision notice and Privacy policy are available under Patient info drop down.

Social Prescribing offers further support in managing your condition or situation - click to watch the video

Health A-Z (Self Care)

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Depression Self Assessment

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BMI Calculator

Opening Times

Monday
08:30 until 18:30
Tuesday
08:30 until 18:30
Wednesday
08:30 until 18:30
Thursday
08:30 until 18:30
Friday
08:30 until 18:30
Saturday
CLOSED
Sunday
CLOSED

Useful Links

Seymour House and Lock Road Surgeries

Online Registration

Patient details

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

If you need a doctor to dispense medicines and appliances

Signatures

NHS Organ Donor Registration

NHS Blood Donor Registration

Opening Times

Useful Links

Join our Patient Participation Group

Friends & Family Test