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New Patient Registration Form

Before you complete this form, please ensure you have to hand:

  1. Name and address of your previous GP practice, if you have one
  2. Your NHS number
  3. Your Photo ID, such as a driving license, identity card or passport (if you have one)

OUT OF AREA REGISTRATION (without home visits)

Information for consideration prior to registration.

You have requested to register with our Practice as an ‘Out of Area’ patient. You live outside the practice boundary (catchment area) and we want to make you aware of what this means for you under this type of registration.

We may decide that it is not in your best interests or practical for you to be registered.

Please read the details below and give careful consideration to your request to register with our Practice. An important consideration you should make is that we are not required to provide you with a home visit.

You may on occasion, develop an urgent illness or injury at home that means attending our Practice would not be possible.

If you have an urgent care need we will ask you to call NHS 111 and they will put you in touch with a local service (this may be a face to face appointment with a local healthcare professional or a home visit where necessary).

In these circumstances NHS 111 will direct you to the local service that has been established by NHS England for patients such as you. This local service could be a GP practice near to where you live, the local walk-in or urgent care centre, A&E or minor injuries unit.

If this is in the out-of-hours period when GP surgeries are normally closed – between 6:30pm and 8:00am weekdays, bank holidays or weekends – NHS 111 will direct you to the local out-of-hours provider.

If your application is considered the practice will only register you without home visits if it is clinically appropriate and practical in your individual case. To do this we may:

  •  Ask you or the practice you are currently registered with questions about your health to help decide whether to register you in this way 
  • Ask you questions about why it is practical for you to attend this practice (for example, how many days during the week you would normally be able to attend)

If accepted, you will attend the Practice and receive the full range of services provided as normal other than home visits, you may not be able to access other certain services also such as

  • District Nurse Services
  • Mental Health Services
  • Social Care Services
  • Health Visiting Services

Also, if you are an out of area patient we will review your medical notes on a 3 monthly basis to ensure we are providing a safe clinical service that is tailored to your needs. If we feel that we cannot meet your health needs we will ask you to register at a GP closer to your home address and we will remove you from our list.

Patient's Details

Information we need to register you with the practice
Please note all fields marked with a * are mandatory for your registration

Communication and Access Needs

Are you an ‘Assistance Dog’ user?

The Equality and Human Rights Commission define assistance dogs as dogs trained to help people with hearing difficulties, epilepsy, diabetes, physical mobility problems and more.

Emergency Contact
Previous Details
Please include postcode
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:
If you are from abroad
Please use this date format: DD/MM/YYYY
If you are returning from abroad

Previously been registered with the NHS in the UK

Please use this date format: DD/MM/YYYY
Please use this date format: DD/MM/YYYY
Supplementary Questions

Anybody in England can register with a GP practice and receive free medical care from that practice.

However, if you are not ‘ordinarily resident’ in the UK you may have to pay for NHS treatment outside of the GP practice. Being ordinarily resident broadly means living lawfully in the UK on a properly settled basis for the time being. In most cases, nationals of countries outside the European Economic Area must also have the status of ‘indefinite leave to remain’ in the UK.

Some services, such as diagnostic tests of suspected infectious diseases and any treatment of those diseases are free of charge to all people, while some groups who are not ordinarily resident here are exempt from all treatment charges.

More information on ordinary residence, exemptions and paying for NHS services can be found in the Visitor and Migrant patient leaflet, available at reception. Alternatively for more information go to

You may be asked to provide proof of entitlement in order to receive free NHS treatment outside of the GP practice, otherwise you may be charged for your treatment. Even if you have to pay for a service, you will always be provided with any immediately necessary or urgent treatment, regardless of advance payment.

The information you give on this form will be used to assist in identifying your chargeable status, and may be shared, including with NHS secondary care organisations (e.g. hospitals) and NHS Digital, for the purposes of validation, invoicing and cost recovery. You may be contacted on behalf of the NHS to confirm any details you have provided.

I declare that the information I give on this form is correct and complete. I understand that if it is not correct, appropriate
action may be taken against me.

A parent/guardian should complete the form on behalf of a child under 16.

European Economic Area (EEA) Country

For a list of EEA countries visit:

If you are visiting from another EEA country and do not hold a current EHIC (or Provisional Replacement Certificate (PRC))/S1, you may be billed for the cost of any treatment received outside of the GP practice, including at a hospital.

Please enter the details from your EHIC or PRC below.

S1 Form

Please give your S1 form to the practice staff.

How will your EHIC/PRC/S1 data be used?

By using your EHIC or PRC for NHS treatment costs your EHIC or PRC data and GP appointment data will be shared with NHS secondary care (hospitals) and NHS Digital solely for the purposes of cost recovery. Your clinical data will not be shared in the cost recovery process.

Your EHIC, PRC or S1 information will be shared with The Department for Work and Pensions for the purpose of recovering your NHS costs from your home country.

Book appointments and order repeat prescriptions online. 

You can book appointments at the practice, request repeat prescriptions for any medications you take regularly and view your medical record securely online using Patient Access. 

Being able to see your record online might help you to manage your medical conditions. It also means that you can access it from anywhere in the world should you require medical treatment on holiday. 

The service is open 24/7/365 and can be accessed from your home PC, Tablet or Mobile at or with the Patient Access app for Apple and Android devices.

Only following file extensions are allowed: jpg, jpeg, png, webp, pdf, doc, docx, pptx
Ethnicity & Religion
Height / Weight / Blood Pressure
Physical Activity
Your Personal Alcohol Consumption

alcohol consumption Image 1 unit

Audit Score Result

you have a score of 

If you are drinking less than 14 units of alcohol per week, then your drinking is within the UK Chief Medical Officers' low risk drinking guidelines.

But if you are drinking regularly at or above the low risk guidelines of 14 units a week, or, you are drinking six or more units - if you are female - or eight or more units - if you are male - in one single session (binge drinking), please consider the increased serious risks to your health being caused by your current drinking pattern.

Smoking Status
Medical History
Please include dates.
Please include dates.
Please include dates.

Over 75 years old?

The Department of Health has advised that all patients of 75years and older have a named and accountable GP to oversee their care. Please ask the name of the GP assigned to oversee your care. Please note this does not prevent you from seeing the GP of your choice.

Adult Females
Please use this date format: DD/MM/YYYY.
Immunisation History
Please include dates.
Patient Participation Group (PPG)

The Practice is committed to improving the services we provide to our patients. To do this, it is vital that we hear from our patients about their experiences, views, and ideas for making our services better. By expressing your interest, you will be helping us plan ways of involving patients to help us improve our services in a way that suits you. It will also mean that we can keep you informed of opportunities to give your views and up to date with developments within the Practice.

If you are interested in getting involved in the PPG, please tick yes in the box below and ask the Receptionist on-duty for the PPG joining form.

Other information
Only following file extensions are allowed: jpg, jpeg, png, webp, pdf, doc, docx, pptx

NHS Organ Donor registration

For more information on organ donation please visit:

NHS Blood Donor registration

If you would like to join the NHS Blood Donor Register as someone who may be contacted and would be prepared to donate blood, please visit their website on: or call direct on 03001232323

What happens to my information?

Personal and medical information about patients registered at this practice are primarily kept electronically, although some is kept in paper form. Some information will be sent to hospital consultants and other health professionals to whom you are referred by your GP in order to provide continued healthcare and obtain treatment for you.

We sometimes use accredited suppliers for our communication with you, for example when we send recall letters for review clinics or medication reviews. All suppliers we use are checked carefully to ensure they comply with strict confidentiality protocols.

To ensure the security of all patient information, all staff that has access to your records is covered by confidentiality clauses in their contracts and the Data Protection Act and the Freedom of Information Act. Our guiding principle is that we hold your records in strict confidence.

I certify that the information I have provided is correct and consent to my personal and medical information being used as stated above.

NHS Research & Planning 

National Initiative 

Your health and adult social care information supports your individual care. It also helps the NHS to research, plan and improve health and care services in England. Unless you have chosen to opt out, your confidential patient information can be used for research and planning.

To opt out of NHS Research and Planning, go to;

You can opt out online by providing your address and NHS number.  

Health Information Exchange

Local Initiative

We're joining up your health and care information to improve the local services you recieve. 

What does this mean for you?
Health and care professionals invovled in your care will be able to see your information and make quicker and safer decisions about your care. 

For more information, including how to opt-out
click here

Summary Care Record

National Initiative

If you have a Summary Care Record your health care providers can view your medication, bad reactions to medications and allergy information when treating you in an emergency or when your practice is closed. 
Patient declaration

In accordance to the NHS Constitution, the first duty of The Bloomsbury Surgery is to provide a comprehensive service, available to all irrespective of gender, race, disability, age, sexual orientation, religion, belief, gender reassignment, pregnancy and maternity or marital or civil partnership status.

To help render this essential service, the Constitution makes certain provisions of which the more important are stated overleaf. It is important for you to know and understand those provisions.
For further information on the NHS Constitution, please visit:


I hereby declare and confirm that the personal details and home address that I have provided are complete, accurate and free of error. I bear the responsibility for the correctness of these details.
As stated in the NHS Constitution, I must provide accurate information about my health, condition and status. I therefore acknowledge that if the home address that I have provided is found and proven to be inaccurate I will be de-registered from The Bloomsbury Surgery, as residing outside the Practice catchment (boundary) area. It will be my responsibility to then find and register with a new GP Practice closer to my home address. I understand that I may be able to re-register at The Bloomsbury Surgery under the Out of Area scheme, at the discretion of the Practice.

I understand that it is my responsibility to inform Swiss Cottage Surgery if any of the details I have provided change as soon as possible.

Privacy Consent

This form collects personal and medical information about you. We use this information to allow the practice team to contact you. Please read our Privacy Policy (opens in a new tab) to discover how we protect and manage your submitted data.


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