Forms & Policies

The following forms can be printed for submission to the practice on paper. Please do not e-mail completed forms to us.

Acceptable forms of identification are: Passport (photo ID); Drivers Licence (photo ID); Bus Pass (photo ID); Student card (photo ID); Household Bill (address ID); Bank Statement (address ID); Marriage Certificate; Birth Certificate.

New Patient Registration (adults)

To register as a new patient aged 16 or over

New Patient Registration (under 16)

To register a child aged under 16 as a new patient
Online Access Application To register with SystmOnline to order your repeat medication and book appointments online
Access To My Medical Record To apply for full access to your medical record (with SystmOnline)
Online Proxy Access To nominate someone to manage your online account on your behalf
Travel Information and Assessment Risk assessment for patients heading abroad who require vaccinations
Change of Address For patients moving house to a new address in our catchment area
Patient Participation Group (PPG) Application to join our face-to-face patient participation forum
Subject Access Request (SAR) To request copies of your medical records, both electronic and/or legacy paper records
Carers Form To register yourself as a carer
Home Blood Pressure Monitor To record your Blood Pressure at home for 24 hours and for returning to the practice

Mission Statement - Our Vision & Values

For our Patients
  • To provide effective, efficient and safe healthcare services for our patients.
  • To treat our patients fairly and equally; with dignity and respect.
  • To listen, communicate, consult and collaborate with our patients.
  • To provide an environment that is welcoming, caring and accessible for all our patients.
For our Practice and Locality
  • To work with others to improve the health of our patients and the local population.
  • To deliver healthcare in modern and fully equipped premises.
  • To utilize our computer system fully and consistently, and embrace new technologies.
  • To be mindful of cost efficiency and effectiveness, and to minimize waste.
For our Practice Team
  • To maintain a supportive, fulfilling and rewarding working environment for all.
  • To encourage personal development through effective appraisal and training.
  • To listen to all team members and value comments, suggestions and contributions.
  • To project a positive and professional image of ourselves both within and outside the Practice.
  • To work hard and have fun!

How you can help us

  • Please keep the appointment or cancel it well in advance to allow other people to see us.
  • Please book urgent appointments for emergencies only.
  • If you feel you need a longer appointment for your problem, please tell reception at the time of booking the appointment.
  • If you change your name, address or telephone number please inform us as soon as possible.
  • Only call the Doctor out of hours if you can’t wait.
  • For minor ailments and injuries try one of the Urgent Care Centres in East Leicestershire and Rutland.
  • Be polite to the staff as they are just doing their job.
  • The practice operates a zero tolerance policy any patient that is violent or abusive to any member of staff may risk being removed from the practice list.

Your Personal Health Information

We ask you for information and keep it together with details of your care.  We may use some of this information to help us to protect the health of the Nation, to help plan the future of the NHS, to train tomorrow’s clinical staff and to carry out research for the benefit of everyone.  You have a right of access to your health records.  Please ask at the reception for further details. There will be a fee for this.

Everyone working for the NHS has a legal duty to keep information about you confidential.


You can find more information on our Medical Record Information page


Suggestions and Complaints

How to make a complaint

At Billesdon Surgery we take complaints very seriously and try to ensure that you are pleased with your experience of our service. Complaints are dealt with courteously and promptly so that the matter is resolved as quickly as possible. This procedure is based on these objectives.

Our aim is to react to complaints in the way in which we would want out complaint about a service to be handled. We learn from every mistake that we make and respond to your complaints in a caring and sensitive way.

To make a complaint please click here to open the Patient Complaint Form. You can also access our patient leaflet which provides further information about how we handle your complaint by clicking here.

The persons responsible for dealing with all complaints is Dr Cooke or the Practice Manager. We will acknowledge your complaint in writing normally within three working days. We will seek to investigate the complaint within ten working days of receipt to give an explanation of the circumstances which led to the complaint. If you do not wish to meet us, then we will attempt to talk to you on the telephone. If we are unable to investigate the complaint within ten working days we will notify you, giving reasons for the delay and a likely period within which the investigation will be completed.

We will confirm the decision about the complaint in writing immediately after completing our investigation. Proper and comprehensive records are kept of any complaint received. If you are not satisfied with the result of our procedures then a complaint may be made to:

Health Service Ombudsman

The Parliamentary and Health Service Ombudsman
Mosley Street
M2 3HQ
Tel: 0345 0154033

The Patient Advice and Liaison Service( PALS)

Email: This email address is being protected from spambots. You need JavaScript enabled to view it.
Tel: 0116 295 0830

NHS England

NHS England
PO Box 16738
B97 9PT
Tel: 0300 3112233
Email: This email address is being protected from spambots. You need JavaScript enabled to view it.




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Catchment Area


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