KHC New Patient Registration Form

NHS England

Register with the practice

Please fill out the registration form below and the applicable questionnaire

Adult New Patient Questionnaire Under 16 New Patient Questionnaire
  • Patient details

  • DD slash MM slash YYYY
  • Please help us trace your previous medical records by providing the following information

    (Please type N/A in the boxes in this section if not applicable)
  • If you are from abroad

    (Please type N/A in the boxes in this section if not applicable)
  • DD slash MM slash YYYY
  • DD slash MM slash YYYY
  • If you are returning from the armed forces

  • DD slash MM slash YYYY
  • If you are registering a child under 5 / If you need your doctor to dispense medicines and appliances

  • If you need your doctor to dispense medicines and appliances

    Not all doctors are authorised to dispence medicines
  • NHS Organ Donor Registration

  • NHS Blood Donor Registration

    For more information, please ask for the leaflet on joining the NHS Blood Donor Register
  • MM slash DD slash YYYY
  • Signature

  • Supplementary Questions

  • This field is for validation purposes and should be left unchanged.

All fields marked with * are mandatory.

About This Form

Please note that we will not respond to any medical information or questions received through the survey.
The information you supply us will be used lawfully, in accordance with the Data Protection Act 1998. The Data Protection Act 1998 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.
Please note that by using this form you will be sending information about yourself across the Internet. Whilst every effort is made to keep this information secure, you should be aware that we cannot offer any guarantees of absolute privacy. If this matter concerns you then you should use another method of registration.
Personal information retained on this system is stored in a secure data centre located in the UK and is treated as confidential.

Are my details secure?
The internet is not a secure place, however, we have gone to great steps in making sure the information you submit to us is as secure as possible.
We use SSL (Secure Socket Layer) certificates to encrypt the communication between your computer and our web server. When you submit your information, it is safely transmitted over the web in an encrypted form and deciphered using the private key at its intended location.

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