New Patient Application Form

We are pleased to be able to accept new patients on a limited basis. This will only include patients who do not currently have a GP in the surrounding area. Please complete the form below to apply to join the practice. Please note that applications will be reviewed on a weekly basis. You will then be contacted about your application.

Please note you will not be a registered patient until we have confirmed and processed your application. Unfortunately, due to capacity issues, we will be unable to accept all applications.

Your Details:

* Required field.

First Name

Second Name

Mobile Phone

Date of Birth

Home Address

PPSN

Name of Previous GP (if none, please state none)

Name of previous GP Practice

Please list your current medications

Medical card / Doctor Visit Card Status

Yes

If GMS/DVC please provide number

Details of dependents under 16 you are also applying for:

Dependent 1 - First Name

Dependent 1 - Last Name

Dependent 1 - Date of Birth

Dependent 1 - Gender

Dependent 1 - PPSN

Dependent 1 - Medical / Doctor Visit Card

Dependent 2 - First Name

Dependent 2 - Last Name

Dependent 2 - Date of Birth

Dependent 2 - Gender

Dependent 2 - PPSN

Dependent 2 - Medical / Doctor Visit Card

Dependent 3 - First Name

Dependent 3 - Last Name

Dependent 3 - Date of Birth

Dependent 3 - Gender

Dependent 3 - PPSN

Dependent 3 - Medical / Doctor Visit Card

Dependent 4 - First Name

Dependent 4 - Last Name

Dependent 4 - Date of Birth

Dependent 4 - Gender

Dependent 4 - PPSN

Dependent 4 - Medical / Doctor Visit Card

Please read and check:

I consent to being contacted by Dargle Clinic and confirm that the information provided above is correct. I understand that I am not a patient of the practice until I receive confirmation that my application is successful.

Yes

I have read the practicePrivacy Statement.

By submitting this form you will be sending personal/sensitive information about yourself across the Internet. Please read our privacy statement to discover how we protect and manage your submitted data. 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 contacting the practice.

New Patient Application Form

Contact

Opening Hours

Links

For Life Threatening Emergencies - Call 999