Tell us whether you accept cookies

We've put some small files called cookies on your device to make our site work. We would also like to use analytical cookies to understand how our site is used and improve user experience. Analytical cookies send information to Google Analytics.

Let us know your preference. We will use a cookie to save your choice. Before you make your choice you can read more about our cookie policy.

Skip to main content

Vernon Street Medical Centre NHS GP Surgery in Derby

New patient registration

New Patient Registration – Adults Only (16+)

Patient’s Details

Title *

Mr

Mrs

Miss

Ms

Other

Please specify:

Surname: *

Previous Surnames:

First Name(s) *

Date of Birth: *

Please use this date format: DD/MM/YYYY.

NHS Number: *

Not sure of your NHS Number? You should be able to find it on any letter or document you have received from the NHS, including prescriptions, test results, and hospital referral or appointment letters.

Gender *

Male

Female

Marital Status *

Married

Single

Widowed

Divorced

Town and Country of birth: *

Postcode: *

Home Address: *

Email Address: *

Any responses we send will go to this email address.

Preferred Phone Number: *

Additional Phone Number:

Can we contact you by email? *

Yes

No

Can we contact you by text/SMS message? *

Yes

No

If you are from outside the UK, your first UK address where you registered with a GP in the UK:

Please include postcode.

If you are from outside the UK, the date you came to live in the UK:

Please use this date format: DD/MM/YYYY.

Previous Details

Previous address in UK:

Please include postcode.

Name and address of previous GP:

If you are returning from abroad

Previously been registered with the NHS in the UK

Date you left the UK:

Please use this date format: DD/MM/YYYY.

Date you returned to the UK:

Please use this date format: DD/MM/YYYY.

If you are returning from the Armed Forces

Address before enlisting:

Please include postcode

Service or Personnel number:

Enlistment date:

Please use this date format: DD/MM/YYYY.

Emergency Contact

Full Name: *

Relationship to you: *

Phone Number: *

Address, if different:

Are they your next of kin? *

Yes

No

Do you give us permission to discuss your medical records with them? *

Yes

No

Ethnic Origin and Language

Please specify the ethnic group you consider you belong to: *

White British

White Irish

Black Caribbean

Black African

Black Caribbean and White

Black African and White

Indian

Pakistani

Bangladeshi

I do not wish to state

Other ethnic group

Please state: *

Do you speak English? *

Yes

No

Do you read English? *

Yes

No

Please specify your first language: *

If you are human, leave this field blank.

The Vernon Street Medical Centre
13 Vernon Street
Derby
DE1 1FW

Get directions

01332 332812

The Lanes Medical Centre
147 Normanton Lane
Littleover
Derby
Derbyshire
DE23 6LF

Get directions

01332 332812

Register with the surgery

Feedback and complaints

Wellbeing

Accessibility statement

Website policies