New Patient Registration

To register with the surgery please call at reception to fill in the necessary forms. To register you must reside within the practice area. Proof of residency (ie a recent utility bill) will be required.

All new patients will be offered an appointment for a health check with the practice nurse in order for us to complete the registration process.

Practice Area Map

This map is meant as a guide only.

Please ask the receptionist if you wish to join the practice but are not sure if you are within the practice boundary.

Our practice area primarily serves Lymm, Warburton and High Legh. There are no on-site parking facilities. The surgery provides parking and suitable access for disabled patients.

map of the practice area

New Patient Registration

Title

First names

Surnames

Previous surnames

Date of Birth

Gender

Town and country of birth

NHS Number

Address

Home Telephone

Work Telephone

Mobile Telephone

Please help us trace your previous medical records by providing the following information

Your previous address in UK

Name of previous GP practice while at that address

Address of previous GP practice

If you are from abroad

Your first UK address where registered with a GP

If previously resident in UK, date of leaving

Date you first came to live in UK

Were you ever registered with an Armed Forces GP

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:

Address before enlisting

Service or Personnel number

Enlistment date

Discharge date (if applicable)

These questions are optional and your answers will not affect your entitlement to register or receive services from the NHS but may improve access to some NHS priority and service charities services.

If you need your doctor to dispense medicines and appliances*

* Not all doctors are authorised to dispense medicines

Do you live more than 1.6km in a straight line from the nearest chemist

Would you have serious difficulty in getting them from a chemist

NHS Organ Donor registration

Please tell your family you want to be an organ donor. If you do not want to be an organ donor, please visit www.organdonation.nhs.uk or call 0300 123 23 23 to register your decision.

I want to register my details on the NHS Organ Donor Register as someone whose organs/tissue may be used for transplantation after my death. Please select the boxes that apply.

Any of my organs and tissue or

Kidneys

Heart

Liver

Corneas

Lungs

Pancreas

NHS Blood Donor registration

All blood types are needed, especially O negative and B negative. Visit www.blood.co.uk or call 0300 123 23 23.

Would you like to join the NHS Blood Donor Register as someone who may be contacted and would be prepared to donate blood.

Have you given blood in the last 3 years

My preferred address for donation is: (only if different from above, e.g. your place of work)

PATIENT DECLARATION for all patients who are not ordinarily resident in the UK

Anybody in England can register with a GP practice and receive free medical care from that practice. However, if you are not ‘ordinarily resident’ in the UK you may have to pay for NHS treatment outside of the GP practice. Being ordinarily resident broadly means living lawfully in the UK on a properly settled basis for the time being. In most cases, nationals of countries outside the European Economic Area must also have the status of ‘indefinite leave to remain’ in the UK. Some services, such as diagnostic tests of suspected infectious diseases and any treatment of those diseases are free of charge to all people, while some groups who are not ordinarily resident here are exempt from all treatment charges. More information on ordinary residence, exemptions and paying for NHS services can be found in the Visitor and Migrant patient leaflet, available from your GP practice.

You may be asked to provide proof of entitlement in order to receive free NHS treatment outside of the GP practice, otherwise you may be charged for your treatment. Even if you have to pay for a service, you will always be provided with any immediately necessary or urgent treatment, regardless of advance payment. The information you give on this form will be used to assist in identifying your chargeable status, and may be shared, including with NHS secondary care organisations (e.g. hospitals) and NHS Digital, for the purposes of validation, invoicing and cost recovery. You may be contacted on behalf of the NHS to confirm any details you have provided.

Please select one of the following statements

I understand that I may need to pay for NHS treatment outside of the GP practice

I understand I have a valid exemption from paying for NHS treatment outside of the GP practice. This includes for

example, an EHIC, or payment of the Immigration Health Charge (“the Surcharge”), when accompanied by a valid visa. I can

provide documents to support this when requested

I do not know my chargeable status

I declare that the information I give on this form is correct and complete. I understand that if it is not correct, appropriate action may be taken against me.

NON-UK EUROPEAN HEALTH INSURANCE CARD (EHIC), PROVISIONAL REPLACEMENT CERTIFICATE (PRC) DETAILS and S1 FORMS

Complete this section if you live in another EEA country, or have moved to the UK to study or retire, or if you live in the UK but work in another EEA member state. Do not complete this section if you have an EHIC issued by the UK.

If you are visiting from another EEA country and do not hold a current EHIC (or Provisional Replacement Certificate (PRC))/S1, you may be billed for the cost of any treatment received outside of the GP practice, including at a hospital.

Do you have a non-UK EHIC or PRC?

If yes, please enter details from your EHIC or PRC below:

Country Code

Name

Given Names

Date of Birth

Personal Identification Number

Identification number of the institution

Identification number of the card

Expiry Date

PRC validity period from

PRC validity period to

Do you have an S1 (e.g. you are retiring to the UK or you have been posted here by your employer for work or you live in the UK but work in another EEA member state).

How will your EHIC/PRC/S1 data be used? By using your EHIC or PRC for NHS treatment costs your EHIC or PRC data and GP appointment data will be shared with NHS secondary care (hospitals) and NHS Digital solely for the purposes of cost recovery. Your clinical data will not be shared in the cost recovery process. Your EHIC, PRC or S1 information will be shared with The Department for Work and Pensions for the purpose of recovering your NHS costs from your home country.

About You

Nationality

Main Language Spoken

Ethnic Origin

Do you have any information or communication support needs relating to a disability, impairment or sensory loss

If yes, please provide details

Height

Weight

Please list any allergies

Next of Kin

Please provide the following information for your Next of Kin

Name

Address

Relationship

Women Only

Please give date of last cervical smear

Carers

Are you a carer

To Whom

Do you support someone who needs help because they are frail or have an illness or disability?

If yes, do you consent to your medical record being coded to this effect

Family History

Please provide the family member/s who have the following conditions and their age at diagnosis

Heart Disease

Stroke

Asthma

Diabetes

Smoking status

Do you smoke

If yes, number of cigarettes a day

Have you ever smoked

If you are a smoker would you like smoking cessation advice

Alcohol

How often do you have a drink that contains alcohol

How many standard alcoholic drinks do you have on a typical day when you are drinking

How often do you have 6 or more standard drinks on one occasion

Do you wish to seek advice/help regarding your alcohol intake

Privacy Protection

Information submitted through secure forms is used only for the purposes of processing your request. We may be in touch with you in relation to the information submitted.

All Information submitted through secure forms is secured with a private key and is accessed over a secure connection by nominated staff. We have a strict confidentiality policy.

This information is not shared with any third party organisations.

This information is retained for up to 28 days.

I consent to my information being used for the purposes described above and wish to submit this online form to Brookfield Surgery • Whitbarrow Road, Lymm, Cheshire, WA13 9DB.

Learn more about our Privacy Policy and Terms of Use. Should you have any concerns about sending your personal details using the web, please use one of the alternative methods offered by our organisation.

Your Neighbourhood Professionals. Just a Click Away!

Key Information

New Patient Registration

Practice Area Map

Privacy Protection