YMG2020/1A New Patient Registration Form

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

Basic Information
Select if you are from the UK or abroad *

UK Abroad
For emails
COVID19 Vaccine Status
Your COVID19 Vaccine Status *
Vaccination Location *
1st Dose Vaccine Type *
2nd Dose Vaccine Type *
Optional Upload of Vaccine Proof

Browse Files

Cancel of
Preferred Site *
Please note that you will still be able to book appointments at any of our 8 sites.
Academic Course *
OT & Nursing Students will require additional occupational vaccinations in order to take part in placements.
First Name *
Surname *
Date of Birth *

Day Month Year
NHS Number *
✎ Don't know your NHS Number? Click here to find it.
Registered Sex *
Gender
Town & Country of Birth *
Address *

Street Address

Street Address Line 2

City
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.
Preferred Telephone Number *
This can be a mobile or landline telephone.
Additional Number
Optional: Please provide a secondary contact number
Email Address
Next of Kin *
NOK: Relationship *
Contact details *
Are you a carer?

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

Yes No
Armed Forces
Address before enlisting

Street Address

Street Address Line 2

City

Postal / Zip Code
Service or Personnel number
Enlistment Date

Day Month Year
Discharge Date

Month Day Year
(if applicable)
Housing *
Previous UK Address *

Street Address

Street Address Line 2

City

Postal / Zip Code
Date you first lived at this address *

Month Day Year
(approximate)
Name of Doctor or Surgery when at that address *
Address of Doctor or Surgery *

Street Address

Street Address Line 2

Post Code
Date arrived in the UK *

Day Month Year
Expected date of leaving the UK *

Day Month Year
Date
Your first UK address where registered with a GP (only if you have previously registered with a GP)

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
If a previous resident in UK, date you left

Day Month Year
Signature *

By signing you agree that the information submitted is Clear

Alcohol Audit
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
Summary Care Record (SCR) - this is an electronic record which contains information about the medicines you take, allergies you suffer from and any bad reactions to medicines you have had. Having this information stored in one place makes it easier for healthcare staff to treat you in an emergency, or when your GP practice is closed. Do you give your permission for us to share the following data?

COVID19 Vaccine Status

HIDDEN SECTION: ANSWER