Brook Street, Sutton in Ashfield, Nottinghamshire, NG17 1ES
Current time is 10:32 - We're open
Telephone: 01623 440018
Latest News (click title to open):
Keeping us all safe
Accessing GP Surgery during COVID
Social Contact Rules from 8 March 2021
The BBC Asian Network has created some great content on vaccines scams
📧 You WILL need a valid email address to complete this form.
Please be aware that we WILL NOT begin the registration process until you attend the surgery with your identity documents, so please come to the surgery within the next 30 days after submitting your form. After this time we will destroy your application and you will have to complete the form again.
Acceptable forms of ID:
• Birth Certificate, Driving Licence, Passport, Utility bill, Allowance book, Solicitors letter, Offer of tenancy, Other official document with your name and address on
• If you need to be seen urgently then you will be registered as immediately necessary until your registration is complete.
• Please get your NHS number from your previous doctors and a list of any repeat medication.
• You must live within the Practice Boundary
Terms & Conditions
a) By completing this form, you are agreeing to us storing your contact information on our secure servers.
b) We will only use your data to deal with your reason for contacting us.
c) Your data is stored on our secure NHS servers and information regarding data that is processed through our website servers can be found on the SurgeryWeb website
d) You can withdraw this consent at any time. Please contact the practice to do so.
e) This form collects only the information you input into it, plus the date: 01/03/2021 and IP address: 184.108.40.206 you are connected to.
ℹ You can opt out of this at any time and we will not pass your number on to any third parties.
✝ If you choose this option we will use the email address provided on this form. You will receive an automated email to verify your address - check your spam/junk folder.
If you do not verify your email address we will not be able to contact you via this method.
Your email address will only be used for the purposes of providing you with healthcare information and will not be passed on to anyone outside of the organisation.
This is usually the address when you were last registered with a GP
You can choose "Other" if not listed below
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.
By completing the section above, I hereby sign this form electronically
What has changed?
Organ donation in England has moved to an 'opt out' system. You may also hear it referred to as 'Max and Keira's Law'.
This means that all adults in England will be considered to have agreed to be an organ donor when they die unless they have recorded a decision not to donate or are in one of the excluded groups.
Your family will still be approached and your faith, beliefs and culture will continue to be respected.
You still have a choice about whether or not you wish to become a donor. Get the facts about organ donation to help you decide.
Who will the changes affect?
These changes will affect all adults in England unless they have recorded a decision not to donate or are in one of the following excluded groups:
• Those under the age of 18
• People who lack the mental capacity to understand the new arrangements and take the necessary action
• Visitors to England, and those not living here voluntarily
• People who have lived in England for less than 12 months before their death
To find out the full facts, visit the website: NHS Organ donation law in England (opens in a new page/tab)
All blood types are needed, especially O negative and B negative. Visit www.blood.co.uk or call 0300 123 23 23.
Some services, such as diagnostic tests of suspected infectious diseases and any treatment of those diseases are free of charge to all people, while some groups who are not ordinarily resident here are exempt from all treatment charges.
More information on ordinary residence, exemptions and paying for NHS services can be found in the Visitor and Migrant patient leaflet, available from your GP practice.
You may be asked to provide proof of entitlement in order to receive free NHS treatment outside of the GP practice, otherwise you may be charged for your treatment. Even if you have to pay for a service, you will always be provided with any immediately necessary or urgent treatment, regardless of advance payment.
The information you give on this form will be used to assist in identifying your chargeable status, and may be shared, including with NHS secondary care organisations (e.g. hospitals) and NHS Digital, for the purposes of validation, invoicing and cost recovery. You may be contacted on behalf of the NHS to confirm any details you have provided.
A parent/guardian should complete the form on behalf of a child under 16.
DO NOT complete this section if you have an EHIC issued by the UK.
For more information on EU and EEA countries, click here: https://www.gov.uk/eu-eea (opens in new tab/window)
Complete this section if you live in another EEA country, or have moved to the UK to study or retire, or if you live in the UK but work in another EEA member state. Do not complete this section if you have an EHIC issued by the UK.
If you are visiting from another EEA country and do not hold a current EHIC (or Provisional Replacement Certificate (PRC))/S1, you may be billed for the cost of any treatment received outside of the GP practice, including at a hospital.
Please tick if you have an S1 (e.g. you are retiring to the UK or you have been posted here by your employer for work or you live in the UK but work in another EEA member state). Please give your S1 form to the practice staff or attach a copy here.
By using your EHIC or PRC for NHS treatment costs your EHIC or PRC data and GP appointment data will be shared with NHS secondary care (hospitals) and NHS Digital solely for the purposes of cost recovery. Your clinical data will not be shared in the cost recovery process.
Your EHIC, PRC or S1 information will be shared with The Department for Work and Pensions for the purpose of recovering your NHS costs from your home country.
Please read below before completing form
👶 New Baby Registrations
• If you are filling this form in for a New Baby, please complete as applicable and sign the declarations on behalf of the patient.
🙎 Adults and Children previously registered elsewhere
Please complete all sections as fully as possible.
• We will need proof of your NAME & ADDRESS so please attend the surgery with ONE of the following:
• Birth Certificate, Driving Licence, Passport, Utility Bill, Allowance Book, Solicitors Letter, Offer of Tenancy, other official document with your NAME & ADDRESS on.
• We CANNOT register you without the name of your previous doctor/surgery so please ensure you provide this information.
• Please sign the Declarations or sign on behalf of children under the age of 11.
For example, if you are completing the form for a child, this is where you put your information as the parent/guardian.
• If you are the patient and your spouse is your next of kin, select 'spouse'.
• If you are the parent/guardian of the new patient you are completing the form for, select 'child'.
They are my:
• 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.
If you are registered with a GP practice in England, you will already have a Summary Care Record (SCR), unless you have previously chosen not to have one. It will contain key information about the medicines you are taking, allergies you suffer from and any adverse reactions to medicines you have had in the past.
Information about your healthcare may not be routinely shared across different healthcare organisations and systems. You may need to be treated by health and care professionals who do not know your medical history. Essential details about your healthcare can be difficult to remember, particularly when you are unwell or have complex care needs.
Having a Summary Care Record can help by providing healthcare staff treating you with vital information from your health record. This will help the staff involved in your care make better and safer decisions about how best to treat you.
You have a choice
You have the choice of what information you would like to share and with whom. Authorised healthcare staff can only view your SCR with your permission. The information shared will solely be used for the benefit of your care.
Your options are outlined below; please indicate your choice on the form below.
• Express consent for medication, allergies and adverse reactions only.
You wish to share information about medication, allergies for adverse reactions only.
• Express consent for medication, allergies, adverse reactions and additional information.
You wish to share information about medication, allergies for adverse reactions and further medical information that includes: your illnesses and health problems, operations and vaccinations you have had in the past, how you would like to be treated (such as where you would prefer to receive care), what support you might need and who should be contacted for more information about you.
• Express dissent for Summary Care Record (opt out).
Select this option, if you DO NOT want any information shared with other healthcare professionals involved in your care.
If you chose not to complete this consent form, a core Summary Care Record (SCR) will be created for you, which will contain only medications, allergies and adverse reactions.
You are free to change your decision at any time by informing your GP practice.
For more information, follow this link: NHS Summary Care Records (SCR)
If you cannot see the image below, please visit click here
click here (opens in new tab/page)
I have been given the opportunity to discuss sharing of my patient record and have read and understood the information “Choosing which organisations can view your record”.
I understand that the same record is used to store information recorded by different members of the care teams who are currently involved in providing my care, including but not limited to doctors surgeries, district nurses, health visitors, physiotherapists, podiatrists, social care and child health.
Please tick one of the following options, I understand that I can change my decision at any time.
If you choose this method you must download the NHS App to your smartphone/tablet app from Google Play or Apple App Store and register yourself
Do you look after a family member or friend who is unwell, disabled or frail?
Once you are added to our list of carers we will know about your busy life as a carer, which can affect your health. We can also try and be flexible with appointments etc as we will know about your commitments.
Name/company name, contact number & their relationship to you.
Your body with start to feel better after 20 minutes, when pulse rate returns to normal. After 8 hours, nicotine and carbon monoxide levels in blood reduce by more than half and oxygen levels return to normal.
Within just 2 days:
• carbon monoxide will be eliminated from the body
• lungs start to clear out mucus and other smoking debris
• there is no nicotine in the body
• your ability to taste and smell is improved
After 72 hours:
• breathing becomes easier
• bronchial tubes begin to relax
• energy levels increase
After 2-12 weeks, your circulation improves. In just 3-9 months, coughs, wheezing and breathing problems improve as lung function increases by up to 10%.
The benefits of quitting smoking increase over a longer time. After:
• 1 year, your risk of heart disease is about half compared with a person who is still smoking
• 10 years, the risk of lung cancer falls to half that of a smoker
• 15 years, risk of heart attack falls to the same as someone who has never smoked
This is not to be confused with a Last Will and Testament
A Living Will is an advanced decision regarding your personal wishes in respect of medical intervention at the time of your end of life (i.e. resuscitation wishes).
If yes, please attach a copy below or bring a copy to the practice when you or your representative comes to verify your identification.
Please complete your application using the "Submit Form" button.
If you want to complete the form later (up to 30 days) please use the "Save and Continue Later" link.
We would like you to think about your recent experiences of our service.