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Out of Area Assessment Form

We will now consider applications from Patients who live outside our boundary. Your information
will be assessed first to ensure that this service is appropriate for you. It is unlikely that you would be suitable to register if you need to be seen on a monthly basis or have needed to use
emergency services regularly in the recent past.

This form will be assessed and if you are found to be suitable then we will inform you that you can complete our registration form to enable us register you and locate your medical record.

Out of Area Assessment Form

Patient’s Details

Please complete text boxes as accurately as possible and select options where appropriate.
Include Flat, Room, Block Number and House Name
Include Flat, Room, Block Number and House Name
Enter Email
Confirm Email

Medical Information

If your request is accepted, you will be able to access our Practice based services however NOT home visits. You will be expected to receive ALL your healthcare needs from us during our normal opening hours. If you have a life threatening medical emergency you should still call 999, go to A&E, ring 111 etc. If you needed these services or that of a ‘Walk in Centre’ quiet often recently it is NOT advisable that you register with us. If your health deteriorates it might be necessary to ask you to register nearer to home. *

Privacy Policy

This form collects your name, date of birth, email, other personal information and medical details. This is to allow the practice team to make a decision about your request and to contact you for further information that may assist in your application. Please read our Privacy Policy to discover how we protect and manage your submitted data.

Please note: There is a slight delay after submitting this form while the information is processed. Please wait for the confirmation of successful submission message before closing this page or navigating away.