New patient registration Form

Thank you for your interest in joining our Middlewood family.

Please take the time to fill in this form.  It may take a little time as it is quite detailed but will allow to have some background information to help us help you from day one of your time with us.

It can take some time for your medical records to arrive with us and so this will allow us to treat you whilst we wait.

If you are unable to answer any questions please leave them blank and this can be picked up in your new patient appointment.

Step 1 of 2

  • New Patient Registration Form

    The information that you provide on this form will be handled in the strictest confidence by both your clinician and the surgery to get to know you and your medical history. If you would prefer to fill this form using a pen and paper you can download the form in the registration section of the website or pick up a copy at the reception. A large print version is available
  • Permanent - you live at the local address full time. Temporary - you are visiting (i.e.returning students in holidays or visiting family/friends) and need medical attention or are in respite - in a Care/Nursing Home.
  • Date Format: DD slash MM slash YYYY
  • This will help to speed up the process. You will find this 10 digit number on a repeat prescription or by contacting your current surgery.