New Patient Questionnaire

1Personal Information

2Next of Kin

3Do you suffer from any of the following?

4Ethnic Group

5Current Medication


Privacy Protection

Information submitted through secure forms is used only for the purposes of processing your request. We may be in touch with you in relation to the information submitted.

All Information submitted through secure forms is secured with a private key known only to the GP practice and is accessed over a secure connection by nominated Practice staff. Our practice has a strict confidentiality policy.

This information is not shared with any third party organisations.

This information is retained for up to 28 days.

Learn more about our Privacy Policy and Terms of Use. Should you have any concerns about sending your personal details using the web, please use one of the alternative methods offered by our organisation.


South Shore Primary Care Centre, Lytham Road, Blackpool, Lancashire, FY4 1TJ
  • Telephone 01253 956655
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