Kibworth: (0116) 279 2422
Mkt Harborough: (01858) 434 523
Fleckney: (0116) 240 4462

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Contact us

The Old School Surgery

Tel: (0116) 279 2422
Open: 8am - 5.30pm Mon - Fri

Mkt Harborough
Two Shires Surgery

Tel: (01858) 434 523
Open: 8am - 5.30pm Mon - Fri

Fleckney Surgery

Tel: (0116) 240 4462
Open: 8am - 5.30pm Mon - Fri
(Closed for lunch 12-2pm)

Out of Hours

If you require medical assistance when we are closed, please call NHS Direct - Tel: 111

Clinics & Services

A range of everyday and specialist services
Home  >  Clinics & Services  >  Patient Forms & Surveys

Patient Forms

Here you will find all the forms you may need, from Change of Address or Travel forms to Sickness Certificates.

Notices and Reports

Primary Care Quality Initiative report


New Patients or Temporary Services

New Patient Registration Form GMS1 (PDF)

New Patient Screening Form (PDF)

Summary Care Record Opt-Out form

Temporary Services Form GMS3/99 (PDF)

Private Patient Form (PDF)


Personal Details

Change of Address Form (PDF)


Travel-related Forms

Travel Risk Assessment (PDF)


Employment-related Forms

Statutory Sick Pay - Employee Statement (PDF)

Patient Surveys

We like to ensure we are always in touch with our patients' needs, therefore please take the time to complete our short survey to help improve our service to you.  

We have established a Patient Panel online forum to help us consult with patients on the facilities and provision of services. Should you wish to be a part of this panel, please register at

Each year we consult with our Patient Participation Group and produce a report on the developments patients would like to see. You can download a copy of the Local Patient Participation Group Report (PDF) for 2015.

In May 2016 we conducted a survey among patients visiting the practice and we have produced a report summarising the results and the actions we propose to take

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