New Patient Registration

If you have recently come to live in Aylesbury, Wendover or the surrounding area and are eligible to register with the practice please use this form. Alternatively, you can download the registration forms.

All newly registered patients are invited to make an initial appointment to discuss their health needs. Please speak to a member of the reception team if you wish to do so.

You will not be registered at Westongrove Partnership until we confirm your registration.

Organ Donation

If you wish to become an organ donor, please visit www.organdonation.nhs.uk.

Practice Boundary

You will also need to reside within our practice boundaries. Each practice within Westongrove has its’ own catchment area.

Required ID

We require two forms of ID which you must present in person – one for proof of identity and one for proof of address. All forms of ID must be valid and proof of address must be no more than three months old.

New Patient Registration

If you are human, leave this field blank.

Select the Practice you would like to register with: * Please select one of the following... Aston Clinton Surgery HP22 5LB Bedgrove Surgery HP21 7TL Wendover Health Centre HP22 6LD

Are you registering a child between the ages of 6-14? *

Yes

No

Are you registering a child aged 5 and under? *

Yes

No

Patient's Details

Title *

Mr

Mrs

Miss

Ms

Other

Please specify:

Surname: *

Previous Surnames:

First Name(s) *

Date of Birth: *

Please use this date format: DD/MM/YYYY.

Gender *

Male

Female

Indeterminate

NHS Number:

Home Address: *

Postcode: *

Town and Country of birth: *

Home Phone Number:

Mobile Phone Number:

Work Phone Number:

Email Address: *

Any responses we send will go to this email address.

Occupation:

Can we contact you by text?

Yes

No

Can we contact you by email?

Yes

No

Ethnicity

Please specify the ethnic group you consider you belong to:

White British

White Irish

Other White

Black Caribbean

Black African

Other Black

Black Caribbean and White

Black African and White

Other Mixed

Indian

Pakistani

Bangladeshi

Other Asian

I do not wish to state

Other ethnic group

Please state:

Do you speak English?

Yes

No

Do you read English?

Yes

No

First Language:

Emergency Contact

Full Name:

Relationship to you:

Phone Number:

Address

Are they your Next of Kin?

Yes

No

Do you give us permission to discuss your medical records with them?

Yes

No

Allergies

Do you have any allergies?

Yes

No

Please specify what you are allergic to, what happens and when you had your first reaction:

Previous Details

Previous address in UK:

Please include postcode.

Name and address of previous GP:

If you are from abroad

Registering for the first time in the UK

Date you came to live in the UK:

Please use this date format: DD/MM/YYYY.

If you are returning from abroad

Previously been a resident in the UK

Date you left the UK:

Please use this date format: DD/MM/YYYY.

Date you returned to the UK:

Please use this date format: DD/MM/YYYY.

HM Forces

Have you ever been a member of the HM Forces?

Yes

No

Enlistment date:

Discharge date:

Carers

Do you have a carer?

Yes

No

Are you a carer for someone?

Yes

No

Name of carer:

Phone Number:

Address:

Do you give us permission to discuss your medical record with your carer?

Yes

No