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New Patient Registration

You can ask reception for a registration pack or alternatively you can fill in the online form below.  If the form does not work you can click here to download this form, print, complete and return to the surgery.

For us to be able to correctly process your registration it is important that the whole form is completed accurately.  Please note; 

  • You should only send this form if you are sure that you are eligible to join this practice.
  • Sending this form will NOT automatically register you with the surgery.
  • Sending this form does NOT guarantee or even imply that you will be accepted onto the practice register

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.


1New Patient Registration

If the patient being registered is under 18 they will need to provide a copy of their birth certificate to the surgery before the process can be completed

2Please help us trace your previous medical records by providing the following information

3If you are from abroad

4If you are returning from the Armed Forces

5If you are registering a child under 5

6If you need your doctor to dispense medicines & appliances*

*Not all doctors are authorised to dispense medicines


8NHS Organ Donation Registration

For more information, please ask for the leaflet on joining the NHS Organ Donor Register

9NHS Blood Donor Registration

For more information, please ask for the leaflet on joining the NHS Blood Donor Register

10EPS Required

The Electronic Prescription Service (EPS) allows prescriptions to be sent direct to pharmacies through IT systems used in GP surgeries. Eventually EPS will remove the need for most paper prescriptions. 99.3% of pharmacies use this system, with approximately 22 million patients using the service nationwide; over 934,226,838 items have been dispensed using EPS. In order to set you up on EPS, we need you to choose a nominated pharmacy where we will send your prescriptions. Some controlled drugs cannot be sent via EPS, if you are unsure if your medication will be sent EPS please check when ordering your medication. Don’t worry; you can change your pharmacy in the future by simply contacting the surgery and asking to change your prescription destination.

11Carers – Do you look after someone who could not manage without you?

There is an estimated 6.5 million people in the UK who provide care for a partner, relative or close friend, some are officially registered as carers and may receive carers allowance, while there are many that don’t. We gather information about carers so we can help to deliver the best possible service.

Carers Details only complete this section if you have a carer.

If yes please provide a copy of the legal documents with your completed form.


From time to time you may want someone to be able to discuss your medical records with us. This could be a partner, relative or close friend. Please consider this option carefully, as if you provide consent for a named person, they will be able to discuss elements of your medical care with us. If you would someone to be able to discuss your care with us, without us requiring additional consent, please provide their details below. For children aged 13 and younger, we will only discuss their care with people deemed to have parental responsibility unless otherwise stated. We reserve the right to refuse access to anyone other than the individual, the medical record pertains to if there are grounds that providing access is likely to cause serious physical or mental harm to the patient or the information you have asked for contains information that relates to a third person.

If yes please provide a copy of the legal documents with your completed form.

13Past Medical History


Please provide the dates you received the following immunisations. If unknown please specify 'unknown'


Do you have any allergies we need to be aware of? If you do please provide details with the entry.

16For Female Patients Only


If you would like help to stop smoking, please contact the local Quit Squad on 0800 328 6297.

18Family History

Has any close relative suffered from the following, if they have please provide details.

19Alcohol Consumption

In brackets after each answer is a score for each answer option. Please note the score for each question and provide the total at the end.

Scoring: A total of 5+ indicates increasing or higher risk drinking. An overall total score of 5 or above is AUDIT-C positive


In brackets after each answer is a score for each answer option. Please note the score for each question and provide the total at the end.

Scoring: 0-7 Lower risk, 8-15 Increasing risk, 16-19 Higher risk, 20+ Possible dependence

Thank you for completing your new patient questionnaire

Although sending information across the Internet means that privacy of data cannot be absolutely guaranteed, our online forms offer high levels of security. The forms use HTTPS and TLS (using a 2048 bit certificate) to encrypt data sent to and from your computer when using the site and our server environment is PCI DSS certified - the highest standard of security associated with e-commerce and online finance solutions.

Form submissions are stored on the server for 28 days and are encrypted and secured with a private key known only by the GP Practice.

Should you have any concerns about sending your personal details using the web, please use one of the alternative methods offered by our organisation.

S N Electrical Mark Ackers Fitness
© Neighbourhood Direct Ltd 2017
Buckshaw Village Health Centre, Unity Place, Buckshaw Village, Chorley, PR7 7HZ
  • Telephone 01772 214 444
Practice Website supplied by Oldroyd Publishing Group
S N Electrical Mark Ackers Fitness
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