To register with us online, please complete the registration form below AND the questionnaire by clicking this link. New Patient Questionnaire

The questionnaire will need to be sent back to us at somccg.victoriaparkmc-admin@nhs.net Thank you.

NOTE: You can save your details and automatically populate this form by creating an account.
Click here to create an account or login.

Patient Registration Form

Please complete the following form to register with us.

Title *
Mr Mrs Miss Ms
Name * First Middle Last
Date of Birth * / DD / MM YYYY
Previous Surname/s
NHS Number *
Town & Country of Birth *
Gender *
Male Female
Address
Street Address Address Line 2 Town/City County/Region Postcode Country
Home Phone
Mobile Phone Number
Work Phone Number
First Spoken Language
Email Address *
Please help us trace your previous medical records by providing the following information
Previous Address *

Street Address Address Line 2 Town/City County/Region Postcode Country
Please help us trace your previous medical records by providing the following information *
Address of Previous Surgery *

Street Address Address Line 2 Town/City County/Region Postcode Country
If you are from abroad
Your first UK address where registered with a GP
Street Address Address Line 2 Town/City County/Region Postcode Country
If previously resident in UK, date of leaving / DD / MM YYYY
Date you first came to live in UK / DD / MM YYYY
If you are returning from the Armed Forces
Address Before Enlisting
Street Address Address Line 2 Town/City County/Region Postcode Country
Service or Personnel Number
Enlistment Date / MM / DD YYYY
If you are registering a child under 5
I wish the child above to be registered with the doctor named overleaf for Child Health Surveillence
If you need your doctor to dispense medicines and appliances*

* Not all doctors are authorised to dispense medicines
I live more than 1 mile in a straight line from the nearest chemist
I would have serious difficulty in getting them from a chemist
NHS Organ Donation registration
I would like to join the NHS Organ Donation Register as someone whose organs may be used for transplantation after my death. Please tick as appropriate
Kidneys Heart Liver Corneas Lungs Any part of my body
NHS Blood Donor Registration
I would like to join the NHS Blood Donor Register as someone who may be contacted and who would be prepared to give blood.
Tick here if you have given blood in the last 3 years
Fore more information, please ask for the leaflet on joining the NHS Blood Doner Register. My preferred address for donation is: (only different from above e.g. near your place of work)
Postcode
Summary Care Record

A Summary Care Record is an electronic record which contains information about the medicines you take, allergies you suffer from and any bad reactions to medicines you have had.

Having this information stored in one place makes it easier for healthcare staff to treat you in an emergency, or when your GP practice is closed.

Click here for a leaflet containing more information.
Please select.. *
If you DO want a Summary Care Record If you DO NOT want a Summary Care Record
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Patient Registration Form

Patient Registration Form

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

If you are from abroad

If you are returning from the Armed Forces

If you are registering a child under 5

If you need your doctor to dispense medicines and appliances*

NHS Organ Donation registration

NHS Blood Donor Registration

Summary Care Record

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