New Patient Registration

If you would like to register with the practice please use this form.

To register a new patient you will need to live within our practice boundary.

If a child would like to register with the Practice please use our Child New Patient Registration form.

New Patient Registration - Hall Green

New Patient Registration - Hall Green

Patient's Details

Title *
Please use this date format: DD/MM/YYYY.
What sex do you identify with? *
Does your gender identity differ from that which was assigned at birth? *
Please state your sexual orientation: *
Do you currently have a fixed address? *

Hall Green Health will continue to register you but they will put your address as the surgery’s address. As soon as you have an address please let us know as it helps us to get hold of you in regards to your care.

Do you live in a care home? *
Any responses we send will go to this email address.
Can we contact you by text? *
Can we contact you by email? *
Have you ever been registered with Hall Green Health before? *
Do you have any information or communication needs such as large print or specific coloured paper? *
Are you happy to travel to the surgery if necessary? *
How would you define your mobility? *

Ethnicity

Please specify the ethnic group you consider you belong to: *
*
*
*
*
*
Do you speak English? *
Do you read English? *
Is English your first language? *
Do you need an interpreter? *

Emergency Contact

Are they your Next of Kin? *
Do you give us permission to discuss your medical records with them? *

Allergies

Do you have any allergies? *

Previous Details

Have you previously lived at another UK address? *
Please include postcode.
Have you been previously registered with another surgery in the UK? *

If you are from abroad

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

If you are under 3 years old you must have a named health visitor. If you do not have one please call the health visitors on 0121 466 4820.

If you are returning from abroad

Previously been a resident in the UK

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

Carers

Do you have a carer? *
Do you give us permission to discuss your medical record with your carer?
Are you a carer for someone? *