Which Practice do you wish to register with?
Nightingale Ailsworth Newborough Parnwell Westwood
Patient’s Previous Details
Please help us trace your previous medical records by providing the following information.
Your Previous address in the UK
Please include postcode
Name of your previous doctor while at that address
Address of previous doctor
Do you have any allergies?
Please specify what you are allergic to, what happens and when you had your first reaction
Does your child take regular medication?
Does your child have any long-term illness, health problem or disability?
Please make an appointment for a new patient health check.
The Electronic Prescription Service (EPS) sends electronic prescriptions from GP practices to pharmacies. Eventually EPS will remove the need for most paper prescriptions.
Would you like to nominate a pharmacy for electronic prescribing?
Name of pharmacy
Your child’s main spoken language
Does your child have any problems reading English? (school age children only)
Does your child have any problems speaking English?
If English is not your child’s main spoken language or yours, do you need an interpreter (someone to help with language) when you visit the doctor?
Please give details of any immunisations your child has received
Please include dates
Brother/Sisters/Siblings (Please give details of Name and Date of Birth)
My Data Matters
If you do NOT wish the NHS to share data from your health records for the purposes of research and planning, please
opt out on the NHS website.
Summary Care Records (SCR)
These are an electronic record of important patient information, created from GP medical records. They can be seen and used bu authorised staff only; in other areas of the health and care system involved in the patients care.
To Opt Out, visit
NHS Organ Donor Registration