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North Gate Uppingham LE15 9EG 01572 823 531
Uppingham Surgery
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New Patient Registration Form – Adult

New Patient Registration Form- Adult

Thank you for applying to join Uppingham Surgery. We would like to gather some information about you and ask that you fill in the following questionnaire. You don’t have to supply answers to all of the questions but what you do fill in will help us give you the best possible care. Please supply two forms of Identification with your completed form, a photographic form of ID (such as passport or driving license) and proof of your home address (such as a recent bank statement or document relating to your new home).

Step 1 of 6

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  • Patient's Details
  • Date Format: DD slash MM slash YYYY
  • Previous address and Postcode
  • Name and Address of Previous GP
  • Date Format: DD slash MM slash YYYY
  • Date Format: DD dash MM dash YYYY
  • Date Format: DD dash MM dash YYYY
  • Date Format: DD dash MM dash YYYY
  • Data Sharing
  • Summary Care Record (SCR) Your SCR is an electronic summary of key medical information taken from your GP medical record. If you need healthcare away from your usual doctor’s surgery, your enhanced SCR will provide those looking after you with key information to help them give you better and quicker care. Please refer to ‘What is a Summary Care Record’ document:

    More information can be found by visiting: https://digital.nhs.uk/

  • The MIG enables secure sharing of relevant medical information from your GP record with other healthcare professionals who are providing you with direct care, even if they are not using the same electronic records system. At point of care you will be asked if you consent to the care service seeing essential elements of your record.

    More information can be found by visiting: https://healthcaregateway.co.uk/?s=products

  • Risk stratification is the process of identifying the relative risk of patients in a population by analysing their medical history. It's a key enabler for improving the quality of care delivered by the NHS.

    Uppingham Surgery is taking part in the Risk Stratification programme and will be uploading patient identifiable data for analysis. Patient identifiable information will only be viewable at GP practice level. Any NHS organisation external to the practice using risk stratification will only see anonymised data.

    For more information please visit our website at www.uppinghamsurgery.nhs.uk

  • Uppingham Surgery use a clinical computer system called SystmOne to record your medical information.

    With your consent, you can allow your full GP record to be shared with other healthcare services that are providing care for you and who also use SystmOne.

    These other services will always ask consent to view your record. For more information please visit our website at www.uppinghamsurgery@nhs.uk

  • Carers Information

    A carer is a friend or family member who gives their time to support a person in their home, to an extent that the person could not remain at home if this care was not being provided.

    A carer can receive Carers Allowance, but not a wage and the care they are giving will significantly affect their own life.

  • Medical Details

    In order to continue to receive your repeat medications you’ll need to make a new patient health check appointment and bring in your last repeat prescription. (Please note, certain medications will require an appointment with the GP before they can be prescribed)

    Please allow plenty of time to organise repeats. Please provide us with your repeat medication list found on the right hand side or a printed prescription.

  • For further information please visit https://www.england.nhs.uk/ourwork/accessibleinfo
  • Family History
  • Smoking Status
  • Please tell us your height, weight and waist circumference
  • Alcohol Consumption This is one unit of alcohol

    And each one of these, is more than one unit

    I want to register my details on the NHS Organ Donor Register as someone whose organs/tissue may be used for transplantation after my death. Please tick the boxes that apply.

    For more information, please visit the website www.uktransplant.org.uk or call 0300 123 23 23

  • Date Format: DD slash MM slash YYYY
  • Signed on behalf of patient (if applicable) (e.g. for minors under 16 years old, adults lacking capacity)
  • If there are any problems with your registration we’ll contact you to clarify any issues, but once your details have been entered into our computerized records…

    On-line Services

    You will be able to register with our on-line service and access appointments, prescriptions and some sections of your own medical record via the internet. All of the details that you need for this are available by requesting to be registered at reception.

    New Patient Health-check

    You will be eligible for a new patient health-check with a Practice Nurse/Health Care Assistant. Contact reception if you should like to take this up.


In this section
  • New Patient Registration Form – Adult
  • Give my feedback
  • Prescription Questions
  • Register for Online Services
  • Request my Test Results
  • Submit an Asthma Review Form
  • Summary Care Record Opt Out Form
  • Synchronising Prescriptions
  • Tests & Results
  • Text Message Reminders
  • Travel Assessment Form
  • New Patient Registration Form – Child under 16

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