New Patient Registration

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

You must then bring one proof of Identification and one proof of Residency to the practice.

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

Personal Details

Please use this Date of Birth format: DD/MM/YYYY
Any responses we send will be sent to this email address.

Consent for Email/Text Correspondence

I give consent and authorisation for the staff at Enderley Road Medical Centre to correspond with me either by email or text, private information about me or for me. I understand that I may revoke this authorisation at any time by submitting my request in writing.

Proof of Identity and Residency

Ethnic Origin

The recording of patients’ ethnic group is necessary as this helps us to identify patterns of illness and need among different ethnic groups. Information on an individual’s ethnic group is strictly confidential as are all other patient details. Access to all your information will be restricted to staff involved in your direct care.

Medical History

Female Patients Only

Family History

Have any of your blood relatives suffered from:

Summary Care Records

All patients at this practice will automatically have a Summary Care Record (SCR) generated. This information will be available to other Health Care Providers with your consent. If you would prefer not to have a SCR, please ask for an Opt Out form at Reception.
More information about the SCR is available at www.nhscarerecords.nhs.uk or telephone 03330142884. Leaflets are also available at Reception.

Electronic Prescription Service

If you would like to use this service, please register at a local pharmacy. However if you are currently using this service elsewhere please remember to de-register from your current pharmacy.

Tuberculosis Screening

Please fill in the questions if you are aged 16 - 35
Were you born or have you spent six months or more in a high incidence country? If yes, select which below.