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Patient Registration

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Patient Registration

Registration

If you live within our practice area and would like to register as a patient with North Shore Surgery practice, you can submit your application in a number of ways:

You can fill in the online per-registration form below. On your first visit to the surgery you will need to sign the form to confirm that the details it contains are correct.
You can visit the surgery and ask the recption staff for a registration form.
You can print off a registration form and GMS1 form, complete it and bring it in with you when you first visit the practice.

GP Registration Form Download GMS1 Form Download

Online Pre-registration

Contact Details
Title*
First Name*
Surname*
Previous Surname (If Applicable)
Address*
Home Contact Number
Mobile Contact Number
Email Address*
Date of Birth*
Place of Birth
NHS Number
Previous Address (If Same As Above enter "Same")*
Previous GP
Previous GP Name
Previous GP Address
Previous GP Contact Number
Next of Kin
Next of Kin Name
Next of Kin Contact Number
Next of Kin: Emergency Contact?*
- Yes
- No
Next of Kin: Can they discuss your medical records on your behalf?*
- Yes
- No
Additional Patient Information
Do you wish to receive SMS reminders regarding appointments and health care?*
- Yes
- No
Do you wish to receive EMAIL reminders regarding appointments and health care?*
- Yes
- No
Are you currently pregnant?
- Yes
- No
Regarding Children: Parental responsibility and school details
Family History Information

The following questions relate to your parents, brothers, sisters and grandparents:
Has anybody ever had raised blood pressure?
- Yes
- No
Has anybody ever had a heart attack?
- Yes
- No
If yes, were they under 60 when it happened?
- Yes
- No
Has anybody ever had a stroke?
- Yes
- No
Has anybody had diabetes?
- Yes
- No
Has anybody had blood clotting problems?
- Yes
- No
- I have no relevant family history
Alcohol

1 drink = ½ pint of beer or 1 glass of wine or 1 single spirit
MEN: How often do you have EIGHT or more drinks on one occasion?
WOMEN: How often do you have SIX or more drinks on one occasion?
How often during the last year have you been unable to remember what happened the night before because you had been drinking?
How often during the last year have you failed to do what was normally expected of you because of drinking?
In the last year has a relative or friend, or a doctor or health workier been concerned about your drinking or suggested you cut down?
Smoking
Have you smoked in the past?
- Yes
- No
If yes, Do you smoke now?
- Yes
- No
If yes, How many do you smoke a day?
If no, When did you quit?
If you are a smoker, are you interested in receiving help quitting?
- Yes
- No
Current Medication

Please list all medications you are currently taking:
Drug 1 Name
Drug 1 Strength
Drug 1 Dose
Drug 2 Name
Drug 2 Strength
Drug 2 Dose
Drug 3 Name
Drug 3 Strength
Drug 3 Dose
Drug 4 Name
Drug 4 Strength
Drug 4 Dose
Do you have any allergies?
- Yes
- No
If yes, which medicines are they?
Ethnic Origin

This questionnaire follows the recommendations of the Commission for Racial Equality and complies with the Race Relations Act.

Please indicate your ethnic origin. This is not compulsory, but may help with your healthcare, as some health problems are more common in specific communities, and knowing your origins may help with the early identification of some of these conditions.
Ethnicity
Main Spoken Language
Care Information
Are you a main carer for someone with a chronic disease?
- Yes
- No
If yes, please provide the following information:
Is the person registered at this practice?
- Yes
- No
Patients Name
Patients Date of Birth
Do you agree to being registered on our system as a carer?
- Yes
- No
Other Information
Why did you decide to register with us?
Where did you hear about us?
Please state if 'other'
Confirmation

We cannot guarantee that the internet is secure, and the transmission of data is entirely at the patient's own risk. The practice accepts no responsibility for breaches in confidentiality resulting from patients' transmissions. If you do not wish to use the online form, please feel free to contact the practice directly on 01253 957 666.
- I accept the terms and conditions above

Missed Appointments

We had a total of 2,706 DNAs during 2018.
Order Prescriptions

You can now order your repeat prescriptions online, ready to pick up.
Order Repeat Prescriptions
Manage Your Health

Manage your clinical records, test results, prescriptions, personal information and appointments online using myGP/Patient Access.
Patient Services

Address

Moor Park Health & Leisure Centre
Bristol Ave, Bispham
Blackpool, Lancashire
FY2 0JG, United Kingdom
Phone: 01253 957666

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01253 957666
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