St Mary's Medical Centre illustration of the medical centre
 
 

 


HOW DO I...
REGISTER?

People wishing to register with St. Mary’s must reside within the practice area, please click here to see our practice area. An application form needs to be completed and these are available from reception. You will also be asked to complete a practice questionnaire about your medical history and/or current medication. This information will assist clinicians whilst waiting for your medical records to arrive from your previous doctor. All patients need an appointment with a nurse for a registration health check before a doctor’s appointment can be made. Urgent cases will be managed on an individual basis.

Under the new GMS Contract patients are now registered with the ‘practice’ rather than an individual doctor. However a patient is entitled to express a preference for the doctor they wish to see and this is recorded on their medical records. You must register with the practice before an appointment can be offered to you to ensure our clinical team have all your patient details. This will include a registration appointment with one of our HCA’s.

ONLINE REGISTRATION

To register online please complete the form below -

Please note that we will need two forms of ID to compete the registration process, for more information please refer to this downloadable document (.doc)

REGISTER DETAILS
  Title:
Date of Birth (DD/MM/YYYY):
Town & country of Birth:
NHS no. (if known):
Sex:
Surname:
First Names:
Home Telephone:
Mobile Telephone:
Work Telephone:
How you describe your
ethnic origin?
Email Address:
Address:
  Postcode:
Are you a carer for a sick/elderly person(s)?
Do you have a carer?

Questionnaire
Marital Status

Religion
Have you been registered at this surgery before?
What is your first language?
Do you require an interpreter?
Occupation OR Name and Address of School
 
Occupation
School Name
  Address 1
Address 2
Postcode
Next of Kin
(Please supply the name, address, telephone number and relationship)
Name
Address 1
Telephone Number
Address 2
Relationship
Postcode

Family History
Do any members of your immediate family have any of the following?
(i.e. mother, father, brothers, sisters, grandparents)
Illnesses Family member, age diagnosed and details
Heart Disease
Stroke
Diabetes
Asthma
Cancer
High Blood Pressure
Glaucoma

Medical Information
List any illness you have had in the past or are taking regular medication for at present.
Illness 1
Medication 1
Illness 2
Medication 2
Illness 3
Medication 3
Other Illnesses or Medication
Are you currently under the care of any specialist?

(If 'YES', please give name, speciality and hospital.)
Name
Speciality
Hospital
Are you on any regular medication?

(If 'YES', please list drug name and dosage prescribed).
Drug 1
Dosage 1
Drug 2
Dosage 2
 
Drug 3
Dosage 3
 
Other Drugs/ Dosage
Are you allergic to any drugs or medicines?

(If 'YES', please list drug and the reaction it caused.)
Drug 1
Reaction 1
Drug 2
Reaction 2
 
Drug 3
Reaction 3
 

About Yourself
Do you smoke?
If 'YES', how many do you smoke a day?
Are you an ex-smoker?
If 'YES', when did you stop?
If you smoke and would like some help in giving up, please contact
"Quitters" on 023 8051 5221, or make an appointment with your doctor.
Female Only
What form of contraception do you use?
When did you have your last cervical smear?

Previous medical records
Your previous address in the UK
  Postcode
Name of your previous doctor at that address
Address of previous doctor
Are from abroad?
Your first UK address where registered with a GP
If previously resident in the UK, date of leaving
Date you came first came to the UK
Are returning from the Armed Forces?
Address before enlisting
  Service/Personnel No.:
  Enlistment date:
NHS Organ Donor Registration
I would like to join the NHS Organ Donor Register as someone whose organs may be used for transplantation after my death.
Please check as appropriate:-
Heart Liver Corneas
Lungs Pancreas Any part of my body

CONFIDENTIALITY - TERMS AND CONDITIONS:
The internet is not secure, and the transmission of this data is entirely at the patient's own risk. The practice accepts no responsibility for breaches in confidentiality resulting from patients' transmissions.

I accept the terms and conditions above

On receipt of your completed application, we will send you a pack with details of our practice and contact you to organise a new patient check.





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