New Patient Questionnaire

Please complete this online questionnaire to provide the practice with information about yourself.

Last Updated: 11/01/2022

Your Contact Details













Information About You








Previous GP


Medical Information







Choice of pharmacy


Carers







Smoking



Alcohol






Family History


Next of Kin


Contacting You


Signature and consent

I declare to the best of my belief this information is correct. By electronically signing below I am consenting to: the choices made in the NHS organ donor register section; the NHS blood donor register if you have selected that preference; and to the Family Doctor Services Registration Form (GMS1) being completed and signed on my behalf by the surgery.