Adult registration

Adult registration form

Last Updated: 14/07/2023

  • Your Contact Details

    Date of Birth
    For example, 15 3 1984
  • Please help us trace your previous medical records by providing the following:

  • If you are from abroad

    Please note, we are unable to process your registration if you do not put a date of entry into UK

    Date you first came to live in the UK (optional)
    For example, 15 3 1984
    You need attend the surgery with proof of address if this is the first time in the UK to complete your registration (optional)
  • If you are returning from the Armed Forces

    Enlistment date (optional)
    For example, 15 3 1984
  • Information About You

    Do you need an interpreter?
    Ethnic Group
  • Medical Information

    Have you ever suffered from? (tick as appropriate) (optional)
    Do you have any allergies, including allergies to any medications?
  • Carers

    Do you have a carer? (optional)
    Are you a carer?
  • Women

    Have you ever had a cervical smear? (optional)
  • Smoking

    If you are an ex-smoker, what date did you stop smoking (optional)
    For example, 15 3 1984
    Would you like advice on giving up smoking?
  • Alcohol

  • Family History

  • Next of Kin

  • For patients aged 65 and over or those with a chronic disease (e.g. asthma or diabetes)

  • Contacting You

    Do you agree that you may be contacted from time to time, via email and/or SMS, with practice news, advice about my health and/or appointment reminders.
  • Summary Care Record

    Summary Care Record (SCR) – used nationally across England

    The SCR is a national database intended to help patient care, particularly in emergencies.  It contains registration details (name, address, date of birth, NHS number etc) and a list of prescribed medication and allergies.  It is useful for an Accident & Emergency department to check for allergies or drug interactions, to improve the treatment they can provide for you.  It is also possible to ask for a more detailed SCR containing significant diagnoses, referrals, vaccinations, care plans or other details.  Your permission will be checked each time, unless there is a special factor such as being unconscious or otherwise unable to consent.  For further information see

    Summary Care Record
  • Oxfordshire Summary Care

    The Oxfordshire Care Summary and the Out – Hours GP records sharing system

    Your patient record is held securely and confidentially on an electronic system controlled by your GP Surgery.  Your information can be viewed if you need treatment in another NHS healthcare setting, such as an Emergency Department, Out of Hours, GP, Minor Injury Unit or College Nurse (if applicable).  The professionals treating you can give you safer care if medical information from your GP Surgery is available to them.  In all these cases, your information will be viewed only by authorised healthcare professionals directly involved in your care.  You will be asked permission before the information is accessed unless the health professional is unable to ask you and there is an important clinical reason for accessing it.

    Please select one option below
  • Signature

    For example, 15 3 1984
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