Out of Area Request - up to 4 Named Patients

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Out of Area Patient Scheme

This form is for new patients outside the normal practice area and for existing patients who move outside the surgery area.

The surgery will endeavour to register any patient irrespective of their address. Patients must sign up for the Out of Area Patient Scheme by completing this form. You would attend the surgery as normal but you would NOT be eligible for any home visits.

In order to proceed please list everyone you wish to be considered and sign the box. 

Completing this form does not guarantee that the practice will accept your application. There are some patients where their condition and the lack of home visits would compromise their care. The application will be discussed by the doctors and you will be informed of the outcome as soon as possible. Where we are unable to take register an out of area patient(s) they will have to register with a surgery serving the new address. 

Privacy Consent

This form collects personal and medical information about you. We use this information to allow the practice team to contact you. Please read our Privacy Policy to discover how we protect and manage your submitted data.

 
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