REG - New Patient Registrations

Please complete this online form to register as a new patient. We look forward to welcoming you to our practice.

Please select your registration type, then hit 'Get started'.
General RegistrationsYSJ Student RegistrationBootham School Registration

You can book appointments at any of our open sites, but which of our surgeries would you most like to attend?
Preferred Site*
Academic Course*
York Medical Group is an inclusive practice, we accept registrations from patients of all backgrounds. To help us get to you know you better please answer the following.
Are you from the UK or abroad?*

UKAbroad
For emails
NHS Number*

Let us know your basic details so that we can begin to register you on our systems.
First Name*
Surname*
Date of Birth*

DayMonthYear
NHS Number*
Sex at birth*
Gender Identity*
Town & Country of Birth*
Todays Date

DayMonthYear
Date
dob
Age in years

Whereabouts are you currenly living?
Address*

Street Address

Street Address Line 2

CityState / Province

Post Code
Postcode*
Bootham Address*
Bootham School, 49-47 Bootham, York
Bootham Postcode*
Address*
Postcode*
Out-of-area patients can access all services from York Medical Group except home visits and urgent treatment. NHS England is responsible for procuring urgent GP services and home visiting should a patient need to be seen where they live.

How should we contact you?
Preferred Telephone Number*
Mobile or landline
Additional Number
Optional
Email Address
Optional
Who should we contact in an emergency?
Next of Kin*
NOK: Relationship*
Contact details*

Let us get to know you better
Are you a carer?

Yes (Informal/Unpaid)Yes (Occupational/Paid)No
Do you have a carer?

YesNo
First Language*
Do you require an Interpreter?

YesNo
Additional communication needs?

YesNo
Please select your additional communication need
Ethnicity*
Religion
How you think of yourself?
Housing Situation*
Military Status
Address before enlisting in the Military

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Service or Personnel number
Enlistment Date

DayMonthYear
Discharge Date

DayMonthYear
(if applicable)

Whereabouts did you used to live?
Previous UK Address*

Street Address

Street Address Line 2

CityState / Province

Post Code
Date you first lived at this address *

MonthDayYear
(approximate)
Which GP surgery where you with before now?
Previous Doctor or Surgery*
Address of Doctor or Surgery*

Street Address

Street Address Line 2

CityState / Province

Post Code

When did you come to the UK, and when are you leaving us?
Date arrived in the UK*

DayMonthYear
Expected date of leaving the UK*

DayMonthYear
Date
If a previous resident in UK, date you left

DayMonthYear
Your 1st UK Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

How many units do you drink in an average week?*
✎ Unsure about units? Click here to use a free calculator.
Are you willing to complete our alcohol audit?*
How often do you have a drink containing alcohol?*
How many units of alcohol do you drink on a typical day when you are drinking?*
How often have you had 6 or more units if female, or 8 or more if male, on a single occasion in the last year?*
Audit C Score
How often during the last year have you found that you were not able to stop drinking once you had started?
How often during the last year have you failed to do what was normally expected from you because of your drinking?*
How often during the last year have you needed an alcoholic drink in the morning to get yourself going after a heavy drinking session?*
How often during the last year have you had a feeling of guilt or remorse after drinking?*
How often during the last year have you been unable to remember what happened the night before because you had been drinking?*
Have you or somebody else been injured as a result of your drinking?*
Has a relative or friend, doctor or other health worker been concerned about your drinking or suggested that you cut down?*
Audit Score

If you needed an organ or blood transplant would you have one? If so, please help those in need of a transplant by opting to donate organs, tissue and/or blood.

Click here to opt in to donate blood

Click here to opt in to donate organs/tissue

Click here to opt out of donating organs/tissue
York Medical Group offers the facility for patients to view online, export or print their full clinical summary from the 1st April 2016. To register for online access you will be required to provide a copy of your photo identification such as a Driving Licence or UK Passport.

Click Here: For more information about access to online records

Click Here: To request online access to your medical records
Signature

Clear
By signing you agree that the information submitted is correct
HIDDEN SECTION: ANSWER

This section will be hidden to patients. It is used for coding calculations only.
Gender Code
GMS1 CODE
INFORMED OF NAMED GP
PATIENT ALLOCATED NAMED GP
Alcohol Audit Compliance
Alcohol Modulator
Audit C Scoring code
Audit Scoring code
Are you a carer?
Do you have a carer?
Do you require an Interpreter?
Armed Forces
Housing
Do you smoke?
How many units do you drink in an average week?
Height
Weight
First Language
Additional Communication Needs
Ethnicity
Religion
Orientation
Your medications, allergies & adverse reactions
Your medications, allergies & adverse reactions & additional information?
Do you consent for us to share your medical records with other medical service you may be using i.e. District Nurse Teams, Podiatry or Dieticians?
Do you give explicit consent for us to CONTACT YOU via text message?
Would you like to be involved in our Patient Participation Group?
Should be Empty:

HIDDEN SECTION: ANSWER