New Patient Registration

Page {{ paginatorProps.current }} of {{ }} ({{ paginatorProps.percentage }}% completed)

New Patient Health Questionnaire

Welcome to Elsdale Street Surgery. Thank you for taking the time to register with us. In order for us to get to know our new patients and to help us offer you the right services, we ask that you fill in this simple questionnaire. We will treat the information that you provide in the strictest of confidence and in accordance with legislation. Following on from the questionnaire, an appointment will be made for you to see one of our nurses who will complete a couple of routine checks which will provide us with an opportunity to get to know you better. More information about this is found in the ‘New Patient Information’ leaflet. If you have any questions, or are not quite sure of how to answer these questions, one of our Receptionists will only be too happy to help.

Personal Details

Information we need to register you with the practice
Please note all fields marked with a * are mandatory for your registration

Ethnicity & Religion
Previous Details
Please include postcode
If you are from abroad
Please use this date format: DD/MM/YYYY
If you are returning from abroad

Previously been registered with the NHS in the UK

Please use this date format: DD/MM/YYYY
Please use this date format: DD/MM/YYYY
Medical History

You can use the practice facilities.

Family History
Your Personal Alcohol Consumption

1 unit of alcohol is 218ml cider standard 4.5% ABV, 76ml Wine Standard 13% ABV, 25ml Whisky Standard 40% ABV, 250ml Beer Standard 4% ABV or 250ml Alcopop Standard 4% ABV

Immunisation History
Only following file extensions are allowed: jpg, jpeg, png, webp, pdf, doc, docx, pptx
Women's Health
HIV Test

Privacy Consent

This form collects personal and medical information about you. We use this information to allow the practice team to contact you. Please read our Privacy Policy to discover how we protect and manage your submitted data.


There appears to be a problem loading the form, please refresh the page.
If the error persists please contact us.