Register as a new patient form

If you would like to become a patient at our surgery, you will need to register your details with us.  

Complete the form below to register as a new patient at the surgery. The form should take less than ten minutes to complete. If you need any help, please call the surgery for us to help you. 

New Patient Registration Form – Adult

Please complete this form in full without missing any fields

If you have moved to the UK, please provide copies of your medical records from abroad

Your title
Sex assigned at birth
Gender identity
An NHS number is a 10-digit number, like 485 777 3456. If known, please enter your NHS number in the field below. You can find more information on the NHS website
SMS consent
I consent to be contacted by SMS
Email consent
I consent to be contacted by email
Preferred contact
Are you happy for us to discuss your medical records with your next of kin?
Overseas visitor
Armed forces
Are you subject to DoLs?
What is your main spoken language?
Do you need an interpreter?
Do you have any communication needs?
Communication needs
If you said Yes in the previous question, please choose one of the options
Are you able to use information technology e.g., computers?
Do you have a learning disability?
Are you a carer?
Who are you a carer for?
Do you have a carer?
* Only add carer’s details if they give their consent to have these details stored on your medical record


Please answer the following questions which are validated as screening tools for alcohol use

How often do you have a drink containing alcohol?
How many units of alcohol do you drink on a typical day when you are drinking?
How often have you had 6 or more units if female, or 8 or more if male, on a single occasion in the last year?


Do you smoke?
If yes, how many cigarettes a day
Do you use an e-Cigarette?
Would you like help to quit smoking?
Are you on contraception?
Are you currently pregnant?
Electronic prescribing
Please provide details of the pharmacy you would like to use: You can request your medication by registering for online services, or by emailing:
Would you like to be involved in our Patient Participation Group?
We are committed to improving the services we provide. The Patient Participation Group is a mechanism for us to gain valuable feedback from our patients about their experiences, views, and ideas for improving our services.

Sharing Your Health Record

What is your health record

Your health record contains all the clinical information about the care you receive. When you need medical assistance it is essential that clinicians can securely access your health record. This allows them to have the necessary information about your medical background to help them identify the best way to help you. This information may include your medical history, medications, and allergies.

Why is sharing important?

Health records about you can be held in various places, including your GP practice and any hospital where you have had treatment. Sharing your health record will ensure you receive the best possible care and treatment wherever you are and whenever you need it. Choosing not to share your health record could have an impact on the future care and treatment you receive. Below are some examples of how sharing your health record can benefit you:

· Sharing your contact details - this will ensure you receive any medical appointments without delay

· Sharing your medical history - this will ensure emergency services accurately assess you if needed

· Sharing your medication list - this will ensure that you receive the most appropriate medication

· Sharing your allergies - this will prevent you being given something to which you are allergic

· Sharing your test results - this will prevent further unnecessary tests being required

Is my health record secure?

Yes. There are safeguards in place to make sure only organisations you have authorised to view your records can do so. You can also request information regarding who has accessed your information from both within and outside of your surgery.

Can I decide who I share my health record with?

Yes. You decide who has access to your health record. For your health record to be shared between organizations that provide care to you, your consent must be gained.

Can I change my mind?

Yes. You can change your mind at any time about sharing your health record, please just let us know.

Can someone else consent on my behalf?

If you do not have capacity to consent and have a Lasting Power of Attorney, they may consent on your behalf. If you do not have a Lasting Power of Attorney, then a decision in best interests can be made by those caring for you.

What about parental responsibility?

If you have parental responsibility and your child is not able to make an informed decision for themselves, then you can make a decision about information sharing on behalf of your child. If your child is competent then this must be their decision.

What is your Summary Care Record?

Your Summary Care Record contains basic information including your contact details, NHS number, medications and allergies. This can be viewed by GP practices, Hospitals and the Emergency Services. If you do not want a Summary Care Record, please ask your GP practice for the appropriate opt out form. With your consent, additional information can be added to create an Enhanced Summary Care Record. This could include your care plans which will help ensure that you receive the appropriate care in the future.

How is my personal information protected?

St. Augustine's Medical Practice will always protect your personal information. For further information about this, please see our Privacy Notice on our website or please speak to a member of our team

For further information about your health records, please see:

For further information about how the NHS uses your data for research & planning and to opt-out, please see:

Do you consent to your GP Practice sharing your health record with other organisations who care for you?
Do you consent to your GP Practice viewing your health record from other organisations that care for you?
Do you consent to having an Enhanced Summary Care Record with Additional Information?

Patients Privacy Notice

If you wish to read our Privacy Notice, please visit Privacy policy page on our website.

How to contact us

If you have any questions about our privacy notice, the personal information we hold about you, or our use of your personal information then please contact our Data Protection Officer at:


Data Protection Officer

St Augustine’s Medical Practice

The Chocolate Factory Block C


BS31 2GN

How to make a complaint

You also have the right to raise any concerns about how your personal data is being processed by us with the Information Commissioners Office (ICO):, 0303 123 1113

Changes to our privacy notice

We keep our privacy notice under regular review. Further information on our practice team, policies and services can be found on our website. If you require a paper copy we can arrange this for you.