Registration Form

Join Our Family Medical Practice

At Cheadle Medical Practice, we know it can be hard to find the right GP nearby. We welcome registration requests from new patients living in or moving to our practice area, in Stockport. We’re based in the heart of Cheadle Village and close to junction 2 and 3 of the M60, so it’s easy to access general practice for our patients . We’re growing all the time, so come and register with your new GP!

To see if you live within our catchment area please utilise our practice boundary tool where you can search your postcode:

Practice Boundary

You can register by completing the form at the bottom of this page, or by visiting us and collecting paper forms from reception.

For further information, click here.

Step 1 of 5

20%

Title(Required)

Mrs

Miss

Master

Other

First Name(Required)

Middle Name(s)

Surname(Required)

Previous Surnames

Date of Birth(Required)

Day

Month

Year

NHS Number(Required)

You can find your NHS number online here: https://www.nhs.uk/nhs-services/online-services/find-nhs-number/

Town of Birth(Required)

Country of Birth(Required)

Address(Required)

Street Address Address Line 2 City County / State / Region ZIP / Postal Code Country

Phone(Required)

You consent to contact about clinical and non-clinical matters via e-mail by filling this in. If you wish to withdraw consent, you may do so at any time by contacting the practice.

Previous Address(Required)

Street Address Address Line 2 City County / State / Region ZIP / Postal Code Country

Please fill this in if you have just moved into our practice area - it helps your GP with locating your previous medical records.

Name and Address of Previous GP (if applicable)(Required)

What is your biological sex?(Required)

Male

Female

Is your gender identity the same as the sex you were assigned at birth?(Required)

Yes

If you have preferred pronouns, please enter them here.

A preferred pronoun is when an individual prefers to be referred to in a certain way, for example "she / her".

What is your sexual orientation?

This is an optional field

Next of Kin - Name(Required)

First Last

Next of Kin - Address(Required)

Street Address Address Line 2 City County / State / Region ZIP / Postal Code Country

Next of Kin - Phone Number

Next of Kin - Relationship to You(Required)

For example, parent / spouse etc.

Diversity Monitoring

White - British

White - Irish

White - Any other White Background

Mixed - White and Black Caribbean

Mixed - White and Black African

Mixed - White and Asian

Mixed - Any other Mixed Background

Asian or Asian British - Indian

Asian or Asian British - Pakistani

Asian or Asian British - Bangladeshi

Asian or Asian British - Any other Asian Background

Black or Black British - Caribbean

Black or Black British - African

Black or Black British - Any other Black Background

Other Ethnic Groups - Chinese

Other Ethnic Groups - Any Other Ethnic Group

Not Stated / Decline to Answer

We are required to keep information regarding a patient's ethnicity on file, so we can monitor equal access to healthcare.

Is English your main language?(Required)

Yes

If no, what is your main language?(Required)

Do you require an interpreter for appointments?(Required)

Yes

Your Background

Are you currently in a care home?(Required)

Yes

Have you ever been a part of the Armed Forces?(Required)

Yes

Do you have any special communications needs?(Required)

Yes

An example would be if you require letters to be sent printed in a larger font.

Please provide details below.(Required)

Do you have any significant mobility issues?(Required)

Yes

If so, do you use a wheelchair?(Required)

Yes

If yes, are you housebound?(Required)

Yes

For this question, 'housebound' means you are incapable of leaving your home. For example, if you can get to your hospital appointments, you are not 'housebound' for the purposes of this form.

Are you blind/partially sighted?(Required)

Blind

Partially Sighted

Neither

Do you have significant problems with your hearing?(Required)

Yes

Do you have a DNACPR (Do Not Attempt CPR) form in place?(Required)

Yes

Does anyone hold Lasting Power of Attorney for Health and Welfare for you?(Required)

Yes

Do you have a carer?(Required)

Yes

If so, please provide their name, relationship with you, and whether they are also a patient at Cheadle Medical Practice.(Required)

Do you consent for us to speak with your carer regarding your care?(Required)

Yes

Are you a carer for somebody else?(Required)

Yes

Who are you a carer for?(Required)

Are you classed as an Asylum Seeker?(Required)

Yes

Would you describe yourself as homeless?(Required)

Yes

Were you born in the UK?(Required)

Yes

Have you previously registered with another UK general practice?(Required)

Yes

Please indicate the date you arrived in the UK.(Required)

DD slash MM slash YYYY

Do you have any previous notes you wish to provide us with? If so, please bring these to the practice.

Yes

Please be aware we can only accept notes written in English.

Are you pregnant?(Required)

Yes

If so, it is your responsibility to ensure you are under the care if a midwife. Speak to reception if you require assistance.

Do you have any learning disabilities?(Required)

Yes

Are you currently on any repeat medication?(Required)

Yes

Please list details of any repeat medication here.(Required)

Children

Is this registration for someone under 16 years old?(Required)

Yes

Who has parental responsibiltity for the child?(Required)

Mother (Sole Responsibility)

Father (Sole Responsibility)

Mother and Father (Joint Responsibility)

Other

A mother automatically has parental responsibility for her child from birth. A father usually has parental responsibility if he’s either married to the child’s mother, and/or listed on the birth certificate (after a certain date, depending on which part of the UK the child was born in).

Does the child have a social worker?(Required)

Yes

Has the child ever had a child protection plan?(Required)

Yes

Please provide details of the child protection plan.(Required)

Digital Access

Important Information

NHS App

We recommend all of our patients get the NHS App. It’s the quickest and easiest way of accessing health services online. Further information can be found on our website. https://www.cheadlemedical.co.uk/services/online-services/nhs-app/

Shared Care Record

As a Stockport resident, you may receive care and treatment from a number of places such as your GP practice, hospital and community services who will all hold information about you. In order to provide the best care, it is important for health professionals to have quick access to the information they need, which may be held by someone else. This is achieved by having a Stockport Health Record and Summary Health Record. We will assume you consent to this, but if you wish to opt out of either or both of these, please write to the practice or contact us via e-mail. Further information can be found on our website.

Electronic Prescription Service (EPS)

The EPS (Electronic Prescription Service) allows prescribers – such as GPs and Nurses – to send prescriptions electronically to a pharmacy of your choice. This makes getting your prescription simpler for patients and staff. We encourage all patients to use this service, but if you wish to opt out you can do so by contacting the practice in writing.

Declaration

Consent

I declare that all of the information I have provided in this form is accurate to the best of my knowledge.

Registration Form

Join Our Family Medical Practice