To register as a new patient online please complete the form below making sure you FULLY COMPLETE both the NHS Family Doctor Services Registration Form and the New Patient Questionnaire that follows it. If you do not complete both of these forms fully we will be unable to register you with the practice.

Please beware that if you have any ongoing medical conditions or take any regular medication then you will need to book an appointment to see the practice nurse for a new patient health check. Please allow two working days after submission of your online registration form before booking this appointment to ensure that you are on our system.

Greenyard Healthcare Waltham Abbey Health Centre 1st Floor Sewardstone Road Watham Abbey, Essex, EN9 1NP Tel: 01992 714088 Fax: 01992 763866 PATIENT DETAILS Mr Mrs Miss Ms Surname: Date of Birth: 01 02 03 04 05 06 07 08 09 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 01 02 03 04 05 06 07 08 09 10 11 12 1895 1896 1897 1898 1899 1900 1901 1902 1903 1904 1905 1906 1907 1908 1909 1910 1911 1912 1913 1914 1915 1916 1917 1918 1919 1920 1921 1922 1923 1924 1925 1926 1927 1928 1929 1930 1931 1932 1933 1934 1935 1936 1937 1938 1939 1940 1941 1942 1943 1944 1945 1946 1947 1948 1949 1950 1951 1952 1953 1954 1955 1956 1957 1958 1959 1960 1961 1962 1963 1964 1965 1966 1967 1968 1969 1970 1971 1972 1973 1974 1975 1976 1977 1978 1979 1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 First names: NHS No: - - Previous Surname:   Male Female Town & Country of Birth: Smoker Yes No Ethnic Origin: I am NOT a student    I AM a student at: Email Address: (your-email@address.co.uk) Home Address:   Postcode: Telephone: Mobile: Current Medication: Past Medical History: Vaccinations: PREVIOUS MEDICAL RECORDS Your previous address in UK Previous GP Details Postcode: Name of previous doctor while at that address: Address of that doctor: Postcode: ARE YOU FROM ABROAD? Please select Yes No Please make your selection above. Please move to the next section. Your first UK address where registered with a GP Other Details Postcode If previously resident in UK, date of leaving Date you first came to live in UK ARE YOU RETURNING FROM THE ARMED FORCES? Please select Yes No Please make your selection above. Please move to the next section. Address before enlisting Service Details Postcode Service or Personnel Number Enlistment date If you need your doctor to dispense medicines and appliances* I live more than 1 mile in a straight line from the nearest chemist - Please select Yes No I would have serious difficulty in getting them from a chemist - Please select Yes No *not all doctors are authorised to dispense medicines NHS Organ Donor Registration I would like to join the NHS Organ Donor Register as someone whose organs may be used for transplantation after my death. Please select Yes No Please check as appropriate:- Kidneys Heart Liver Corneas Lungs Pancreas Any part of my body Sending this form does not guarantee or even imply that you will be accepted onto the practice register. CONFIDENTIALITY - TERMS AND CONDITIONS: The internet is not secure, and the transmission of this data is entirely at the patient's own risk. The practice accepts no responsibility for breaches in confidentiality resulting from patients' transmissions. I accept the terms and conditions above Click 'Submit' to send your details to the surgery, you will then be prompted to complete a New Patient Questionnaire form.