Telephone – 01249 462 775
Email – [email protected]
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Please be aware that it is mandatory to wear a face covering when attending the surgery, Thank You.

Patient Online Registration Form

This page is for patients who are looking to register with our surgery.

This service is available online for Children and Adults.

Newborns are sent a registration form with their 3 week check invitation. If you would like to register a newborn sooner, contact the surgery on 01249 462 775.

For Care Home registrations, please contact the surgery directly.

In order to have a successful application, please follow these steps:

  • Check you live within our catchment area which can be found  via this link:
  • There are 3 different options to choose from next, these are:
  1. Fill out the below form (preferred)
  2. Download the PDF copy of the standard registration form and send this to us electronically or by bringing it into reception
  3. Collect a paper registration form from reception
  • Once the registration form has been returned, please allow between 5-10 working days for this to be processed, in the meantime if you need any urgent medical advice use the NHS 111/999 services or for non emergency’s you can contact your previous practice.
  • Whilst this is not mandatory, we request that you send us a form of Photo ID to go along side your application, this can help us to ensure we have the most accurate and up to date information. Please send this to [email protected] 

Online Patient Registration Form

Family Doctor Services Registration Application form, revised on 01/05/2022

Online Patient Registration Form

Section 1: Patient Details
Title(Required)
Name(Required)
Date of Birth(Required)
If applicable
Address(Required)
If you were born in the UK, please indicted which town. If you are from abroad, please indicate the country you were born in.
This should be in the format: 999 999 9999 You can find this in the NHS app, or following this link. If you do not have an NHS number, please speak to reception

Contact Information

If you are registering a child (under the age of 13) please indicate in the box provided who the mobile / email belongs too including relationship to child. Please also note that we will require written consent from anyone over 13 for another persons contact information to be recorded in their medical records.
By giving this information to Hathaway, you consent to receiving communication from us such as appointment reminders. if you wish to opt-out, please let us know by emailing [email protected] or by calling 01249462775
By giving this information to Hathaway, you consent to receiving communication from us such as appointment reminders. if you wish to opt-out, please let us know by emailing [email protected] or by calling 01249462775
Email Address
By giving this information to Hathaway, you consent to receiving communication from us such as appointment reminders. If you wish to opt-out, please let us know by emailing [email protected] or by calling 01249462775
If this is not the patients contact information, please provide the name and relationship to patient whos contact information this is.

Please tell us about your Previous registration details

Previous Address(Required)

If You Are From Abroad :

First UK address where registered with a GP
If previously a resident in the UK, Date of leaving
Date you first came to live in the UK
Were you ever registered with an Armed Forces GP?(Required)
If yes to the above question, please indicate if you have served in the UK Armed Forces and/or been registered with a ministry of defence GP in the UK or overseas
Date of Military Enlistment (if applicable)
Date of Military Discharge (if applicable)

Now please tell us more about yourself

In this section you will be asked a series of questions relating to your health. Please fill in the information as best you can, this will help us ensure your medical records are as up-to-date as possible
Are you a Carer?(Required)
This question is asking if you are an informal unpaid carer's for a friend or relative. If the answer is yes, please request a 'carer's information' by following this link.
Ethnicity(Required)
Please indicate if you require an interpreter during any surgery visits
Next of Kin
Title
First Name
Surename
 
Next of Kin details
Relationship to you
Conctact Number
Registered Surgery
 
Family Members
Name
Contact Number
Relationship to Patient
 
Please let us know of any close family members that are registered with our practice

Medical History

In this section, you will be asked about your medical history. This will include your personal history as well as family history. Please leave this blank if there is no relevant information.
Have you suffered from any of the following conditions?
Please record and significant family history with the following medical conditions
This recognizes close relatives such as Mother, Father, Brother, Sister, Grandparent etc.

Lifestyle Questionnaire

Please now fill in these personal details to the best of your knowledge. This will help us to provide the most accurate care.
Current Repeat Medication
Name of Medication
Strength (e.g100MG)
Dose (e.g1 a day)
 
Please give us the name of the medication form a repeat template, this can sometimes be different to what is on the package.
The default is Lloyds Pharmacy, Middlefields Road
Please enter your Current Height and Weight(Required)
Height (cm)
Weight (kg)
Contraception(Required)
Are you on any form of contraceptive treatment?
Please indicate what type of contraception do you use? We only need to know about hormonal methods such as the coil or an implant. if you take the pill please indicate the strength, dose and quantity in the 'medications' box above.
Do You Smoke?(Required)
If you do smoke, would you like any support in quitting?
Alcohol Consumption(Required)
If you do drink Alcohol, how many units each week do you drink?
If you drink more than the reccomended amount of alcohol, would you like support in cutting down?

Data Sharing

In this section, we have provided different trusted links to the NHS website which explains in detail about your health records. You will be automatically opted into Sharing your Health Record and Shared Administration. If you have concerns about this before requesting to opt out please do read the information. Our primary goal is to provide the best level of care and sharing your medical information with other Healthcare providers allows this to happen. We will never share your personal information to any untrusted organisations.

Access to Online Services

Hathaway Medical Centre use SystmOnline and the Airmid App, information on these can be found on our website here. This allows access to many different services and may save you a trip to the surgery. To request an online account, please use the following form: Please note this form is only to be completed if you are registering yourself. Please speak to Reception to find out how you can access another persons online services account
Access to SystmOnline(Required)
Which services would you like access to?

Organ Donor

Now that the law has changed, it will be considered that you agree to become an organ donor when you die, if: you are over 18; you have not opted out; you are not in an excluded group. You still have a choice whether or not you want to become an organ donor, and can register or amend your decision at any time. You are automatically opted into becoming an organ donor unless you opt out, you can do this by going to the website
Consent(Required)

 

The following are downloadable PDF versions of the standard Patient Registration Forms.

New Patient Registration Form – Adult

New Patient Registration Form – Child