Permanent Registration

If you live in our practice area and would like to register you can do this online.

Please complete the online form below to register. If your prefer, you can print out our registration form and return by post or hand it in at the practice. Click here for our new patient Registration Forms.

You will be asked to provide two forms of identification when registering with the Practice. Please provide one form of photographic ID (passport or drivers’ licence) and a current utility bill or bank statement to confirm your address. We will contact you via telephone or email to arrange ID verification.

New patients are encouraged to continue to see their own doctor for future problems. This policy, we think, fosters the doctor/patient relationship and improves continuity of care. We do ask patients to avoid registering on a Monday as this is normally our busiest day.

Medical treatment is available from the date of registration.

To also register for online services please click here

"*" indicates required fields

Patient's details

Title*

Mrs

Miss

Your full name*

Date of birth*

DD slash MM slash YYYY

NHS Number - if known

Previous surnames

What do you identify as?*

Male

Female

Other

If you ticked other, please specify what you identify as

Town and country of birth*

Address*

Street Address City or Town County Post Code

Telephone number*

Mobile Telephone number

Enter Email Confirm Email

Please help us trace your previous medical records by providing the following information

Your previous address in UK*

Name of previous GP while at that address*

Address of previous GP practice while at that address*

If you are from abroad

Your first UK address where registered with a GP*

If previously resident in UK, date of leaving*

Date you first came to live in the United Kingdom*

Were you ever registered with an Armed Forces GP

Please indicate if you have served in the UK Armed Forces and/or been registered with a Ministry of Defence GP in the UK or overseas

Regular

Reservist

Veteran

Family Member (Spouse, Civil Partner, Service Child)

Address before enlisting

Service or Personnel number

Postcode

Enlistment date

DD slash MM slash YYYY

Discharge date (if applicable)

DD slash MM slash YYYY

Footnote: These questions are optional and your answers will not affect your entitlement to register or receive services from the NHS but may improve access to some NHS priority and service charities services.

If you need your doctor to dispense medicines and appliances*

I live more than 1.6km in a straight line from the nearest chemist

I would have serious difficulty in getting them from a chemist

*Not all doctors are authorised to dispense medicines

Ethic Origin

NHS organisations are required to collect details about ethnicity. This information is collected to fulfil that obligation and is used for monitoring purposes only.

Ethnic Origin

NHS organisations are required to collect details about ethnicity. This information is collected to fulfil that obligation and is used for monitoring purposes only.

I would describe my ethnic origin as:*

Personal and Family History

There can sometimes be a delay in obtaining medical notes from your last practice, providing this information will be of great help to your doctor. All the information given will be treated as strictly confidential.

Personal Medical History, Please list any serious illnesses, accidents or operations.*

Please list any serious illnesses, accidents or operations, if none apply please write N/A

Current medication, Please provide details of any repeat medications you take, if none please answer N/A*

Allergies*

Do you have any allergies? if so please give details

What reactions of do you have with this allergy

Electronic Prescribing, We can send prescriptions electronically to any pharmacy that you choose. If you would like to use this service please let us know which pharmacy to use*

JHoots Pharmacy, Sedemuda Road, Sidford, Sidmouth, EX10 9YL

Sidmouth Pharmacy, 81 High Street, Sidmouth, EX10 8LD

Boots, Fore St, Sidmouth, Devon, EX10 8AQ

Well Pharmacy, Canaan Way, Ottery St Mary, Devon EX11 1EQ

Boots, 3-5 Broad Street, Ottery St Mary, Devon, EX11 1BT

You can change this in the future if you wish, just let us know.

Current occupation, if retired please list previous occupation*

Disability. Would you regard yourself as having any disabilities (please give details)

Family History

Diabetes

High Blood Pressure

Heart Attack or Angina under the age of 60

Heart Attack or Angina over the age of 60

Asthma

Bowel Cancer

Breast Cancer

Prostate Cancer

Ovarian Cancer

Stroke

Glaucoma

Epilepsy

None

Please tick box if first degree relatives i.e. father, mother, brother or sister has a history of

Blood Pressure Reading*

Weight*

Do you smoke*

Never Smoked Tobacco

Current Smoker

Ex Smoker

If you are a smoker or ex smoker please complete the following questions below. If you smoke we can help you give up. We can offer Nicotine Replacement Therepy medication on prescription and/or help and advice from the One Small Step organisation. Please ring One Small Step on 0800 2982654 or visit their website onesmallstep.org.uk

Number of years smoked

If ex smoker - year you gave up

Cigarettes per day (average)

Cigars per day (average)

Tobacco ounces per day (average)

How many units of alcohol per week do you drink?*

one unit of alcohol = half a pint of beer or 1 small glass of wine or 1 spirit measure

Exercise - Which correctly describes your exercise regime?*

Diet - Which of the following most closely resembles your diet?*

Next of kin details

Full Name of Next of Kin*

Relationship to you*

Next of Kin Phone Number*

I AUTHORISE my General Practitioner to release information regarding my medical condition to the person registered as my Next of Kin*

3 Months

6 months

1 Year

Indefinitely

Not applicable, no Next of kin listed

Please be advised you can add or withdraw your consent about sharing information with your Next of Kin at any time.

Third Party Consent

Please let us know if you would like another person to be able to speak on your behalf regarding your medical information. This could be to book or cancel an appointment, discuss blood test results or general information regarding your medical record.

Full name

Relationship to patient

Address

Street Address Address Line 2 City or town County Post code

Telephone

I AUTHORISE my General Practitioner to release information regarding my medical condition to the named person above.

3 months

6 months

1 Year

Indefinitely

No other third party identified

Please be advised you can add or withdraw your consent about sharing information with any thrid party any time.

Summary Care Record

There is a central NHS computer system called the Summary Care Record (SCR). It is an electronic record of the medicines you take and any allergies or bad reactions to medicines you have had. Storing information in one place makes it easier for healthcare staff to treat you in an emergency, or when your GP practice is closed. This information could make a difference to how a doctor decides to care for you, for example which medicines they choose to prescribe for you. You can choose to opt out of having a Summary Care Record. IF YOU WISH NOT TO CONSENT to having a Summary Care Record please confirm below. If you are completing this form on behalf of a child under the age of 16 you will need to request an additional form from the surgery to opt them out.

Summary Care Record

I wish to opt out of a Summary Care Record

Signature*

Local Health Record

This allows access your full health record to Out of Hours service & Secondary Care Clinicians in Devon only & with you express consent at point of care. This will help with your care. Leaflets are available in the Practice

Local Health Record

I wish to opt out of Local Health Record

Signature*

SMS and Email Consent.

I consent to receive communications from Sid Valley Practice by SMS*

I acknowledge that text messages, emails and voicemails are an additional service and that they may not be sent on all occasions. The responsibility for attending appointments and cancelling them as well as contacting the Practice to obtain the results of recent tests still rests with me. I can cancel the text message and/or email facility at any time. Text messages are generated using a secure facility but I understand that they are transmitted over a public network onto a personal telephone and as such may not be secure. This Service is available for patients 16 and over.

Signature*

I consent to receive communications from Sid Valley Practice by Email*

I acknowledge that text messages, emails and voicemails are an additional service and that they may not be sent on all occasions. The responsibility for attending appointments and cancelling them as well as contacting the Practice to obtain the results of recent tests still rests with me. I can cancel the text message and/or email facility at any time. Emails are generated using a secure facility but I understand that they are transmitted over a public network onto a personal email accounts or landlines and as such may not be secure. We will only send the minimum amount of personal identifiable information needed to convey the message. This Service is available for patients 16 and over.

Signature*

Submission

Thank you on behalf of Sid Valley Pratice. We will process your registation details and be in contact to offer you an appointment to bring in two separate forms of Identification, one of which must be photo ID. Once we have these we can finalise your registration. To submit your registration please submit your details using the button below. Please notify us if your contact details change at any time. Your data is sent and stored securely within the UK using encryption. Cookies must be enabled in your browser for this form to work and by using this this form you are also agreeing to the use of cookies. EU Data Protection Directive 95/46/EC.

Consent*

I agree the information provided is accurate and that I am the named patient completing this form.

Consent*

I agree to the privacy policy.

Please note that no medical information or questions will be responded to. The data you supply on this form will be stored on our website, which is hosted by a third party, until it has been processed by the practice. The data will be used lawfully, in accordance with the Data Protection Act 2018, which gives you the right to know what information is held about you, and sets out rules to make sure that this information is handled properly. The practice privacy policy can be viewed on this website.

Signature*

Date*

DD slash MM slash YYYY

Patient's details

Please help us trace your previous medical records by providing the following information

If you are from abroad

Were you ever registered with an Armed Forces GP

Ethic Origin

Ethnic Origin

Personal and Family History

Next of kin details

Third Party Consent

Summary Care Record

Local Health Record

SMS and Email Consent.

Submission

Helpful links

Further Info