New Patient Registration

If you would like to register with the practice, please use this form.

To register a new patient you will need to live within our practice boundary.

It can take a number of weeks before we receive your medical notes from your previous doctor. We would therefore be grateful if you would fill in the questionnaire for each member of your family, and hand it to us with your medical card, so that we have the essentials of your health record.

We would also invite you to have a free health check with either your new doctor or a practice nurse. This will only take a few minutes and includes measurement of your height, weight, blood pressure and urine testing (please bring a specimen with you).

Temporary Residents

If you would like to register with the practice as a temporary resident, please complete our Temporary Residents form. 

Children Under 16

If you are registering a child under 16, please use our Under 16 New Patient Registration form.

Please give us details of all their immunisations. If they are under five years old, please also contact the health visitor to make sure that they benefit from all the preventative facilities available.

New Patient Registration - Chobham and West End

New Patient Registration - Chobham and West End

Title: *
Sex: *
Married Women only.
Do you live alone?
Marital Status:
The DoH have requested that the practice records the ethnicity of all newly registering patients. Are you willing to have this information recorded? *
Ethnicity:
Do you consider yourself to have a disability? *

We will make adjustments where reasonably practical to ensure you can access our services.

If any of the above details change please inform us as soon as possible so we can amend our records.

Previous Details

Personal Medical History

Please select the boxes if you have had a history of:

Women aged 20-64 Only

Have you had a cervical smear test?
Was the result normal?
Where was it done?
If you are of reproductive age, what means of contraception do you use?

Smoking

Do you smoke? *
What do you smoke?

Smoking Advice

If you would like to give up smoking and need some help, please make an appointment to see the practice nurse.

Alcohol

This is one unit of alcohol:

Amount of different types of drink representing one unit of alcohol

And each one of these, is more than one unit:

Amount of different types of drink representing more than one unit of alcohol
How often do you have a drink that contains alcohol? *
How many standard alcoholic drinks do you have on a typical day when you are drinking? *
How often do you have 6 or more standard drinks on one occasion? *
How often in the last year have you found you were not able to stop drinking once you had started? *
How often in the last year have you failed to do what was expected of you because of drinking? *
How often in the last year have you needed an alcoholic drink in the morning to get you going? *
How often in the last year have you had a feeling of guilt or regret after drinking? *
How often in the last year have you not been able to remember what happened when drinking the night before? *
Have you or someone else been injured as a result of your drinking? *
Has a relative/friend/doctor/health worker been concerned about your drinking or advised you to cut down? *

Family History

Has any first-degree relative (parent, brother or sister) ever had:

A heart attack or angina:
Were they:
Stroke:
Diabetes:
Asthma:

Carers

Are you a carer? *
Are you cared for? *

Next of Kin

Chobham and West End Medical Practice is registered under the Data Protection Act.

This practice has joined the national Summary Care Record programme which enables each patient to have a summary of their key medical information held securely on the NHS central database, known as the NHS Spine. This summary record could be used in an emergency if you needed treatment when access to the medical record held by your GP was not available; for example if you call the doctor out of hours. You will always be asked to give permission for this record to be viewed and you have the right to decline.

Please indicate below whether you would like to have your own Summary Care record by indicating your decision below. A full explanation of each choice follows.

Please select an option: *
  • A Summary Care record will be created for you from the details held on our GP clinical system and will contain:
    • any record we have of your current repeat medication, any acute medication (one-offs e.g. antibiotics) and any recently discontinued medication
    • any record we have of adverse reactions to medication
    • any record we have of your allergies
  •  A Summary Care Record will be created for you containing the details itemised above in 1, plus important additional information you and your GP agree would be useful. (e.g. Diagnoses - Asthma, Diabetes etc.;  Pacemaker,  End of life care etc.) Please discuss this with your GP at your next visit.
  • A note will be made in your records that you do not wish to have a Summary Care Record. Please note that if you attend A&E or if you need emergency treatment when the GP Practice is closed the clinicians treating you may not have access to key information to help them give you the most appropriate treatment.

Online Services

If you would like to book / cancel gp appointments, order repeat medication or view your medical record online, you will need to complete this annex and show a form of id when asked for by the practice.

We now use SMS messaging to remind patients of appointments booked and to send non-personal information. Please indicate If you wish us to use your mobile number or email address for this service, by selecting the appropriate boxes below.

Text Messaging:
Email: