New Patient Registration

If you would like to register with the practice please complete this form. To register as a new patient you will need to live within our practice boundary.

In addition to submitting this online form you need to:

Both the GMS 1 form and copies of your two forms of identification can be emailed to the surgery at ermce84009@nhs.net

New Patient Registration

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

You must provide one example from the list below as proof of Identity for each person over 16 years if age you wish to register.
You must provide one example form the list below as proof of Residency (must be dated within the last 3 months).

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.
Please indicate to which ethnic group you feel you belong.

Medical History

Do you smoke?
Have you ever smoked?

Female Patients Only

Was the result normal?
Are you currently using contraception or taking Hormone Replacement Therapy?

Family History

Have any of your blood relatives suffered from:
Heart Disease
High Blood Pressure
Diabetes
Stroke
Cancer
Other serious illness

Are You a Carer?

Do you look after a family member, partner or friend who needs help because of their illness, frailty or disability?
Do you consent for this information to be entered onto a Carers register and to be recorded on your clinical record?

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.

Online Services

We would encourage you register for online access to be able to view your medical record, test results and to request repeat prescriptions. Please complete this form to register for this.

Tuberculosis Screening

Please fill in the questions if you are aged 16 - 35
Have you been in England less than 5 years?
Have you been tested or treated for TB in the UK?
Were you born or have you spent six months or more in a high incidence country? If yes, select which below.
Countries of origin eligible for LTBI testing and treatment