New Patient Registration

Title: *

Please specify:

We will send appointment reminders etc. to this number unless requested not to do so.

Current Address: *

NHS Number:

First Language: *

Place Of Birth: *

Please give details if you need additional support in communication relating to a disability, impairment or sensory loss:

Do you need an interpreter? *

Yes

No

Are you happy for us to contact you via email? *

Yes

No

Are you happy for us to contact you via text? *

Yes

No

Are you happy for us to leave messages on your answer phone? *

Yes

No

Have you ever served in the armed forces or as a reservist? *

Yes

No

Ethnicity: *

Please specify:

Next of Kin

Title:

Full Name: *

Relationship to Patient: *

Are they registered with this practice?

Yes

No

Home telephone number:

Mobile telephone number: *

Work telephone number:

Can we discuss your record with, and give results to them?

Yes

No

Is this person your emergency contact?

Yes

No

Emergency Contact

Title: *

Full Name: *

Relationship to Patient: *

Main telephone number: *

Please help us trace your previous medical records by providing the following information

Previous Address in the UK:

Name of Previous GP Practice:

Address of Previous GP Practice:

If you are from abroad

Your first UK address where registered with a GP:

Date you left the UK:

Date you first came to the UK:

Were you ever registered with an Armed Forces GP

Please indicate if you have served in the UK Armed Forces and/or been registered with a Ministry of Defence GP in the UK or overseas:

Regular

Reservist

Veteran

Family Member

Address before enlisting:

Service or Personnel Number:

Enlistment Date:

Discharge Date:

Medical Information

Do you have any allergies, if so to what?

Are you taking any medicines or tablets (please list & give dosages)?

Are you registered disabled? *

Yes

No

Please give details:

Do you have any mental health issues? *

Yes

No

Please give details:

Please indicate if you have ever suffered from the following conditions:

Please specify:

Are you receiving or have you received any treatment or therapy? *

Yes

No

Please give details of your care and when you received it:

Lifestyle

Height:

Weight:

Do you smoke? *

Yes

Gave Up

Never

Would you like advice on giving up smoking?

Yes

No

For help and advice please visit www.nhs.uk/smokefree or call 0300 123 1044.

How many cigarettes do you smoke per day?

How many Grams of tobacco per week?

How much exercise do you do?

What exercise do you do?

Alcohol Intake

How often do you have a drink that contains alcohol? *

How many standard alcoholic drinks do you have on a typical day when you are drinking? *

How often do you have 6 of more standard drinks on one occasion? *

Carers

A carer is anyone who cares, unpaid, for a friend or family member who due to illness, disability, a mental health problem or an addiction cannot cope without their support.

Are you a carer?

Yes

No

Please give details:

Do you have a carer?

Yes

No

Please give details:

Join Our Email Group

Help us to improve our services by joining our virtual patient participation group.

If you are happy for us to contact you periodically by email please tick the box.

GDPR

We will not share your contact details with any third party unless for safeguarding reasons (Please refer to our website to find out how your information, including contact details is used/shared)

Electronic Prescription Service

The Electronic Prescription Service (EPS) is an NHS service and enables prescriptions to be sent directly to a chemist of your choice (nominated pharmacy).

If you are unsure of what this means to you please ask at reception for a leaflet on EPS.

Name and address of nominated chemist:

This chemist can be changed by you at any time by letting the surgery know.

EMIS Access

If you would like online access to:

View your medical record
Order repeat prescriptions
View test results
Book appointments

Please read the practice guidance for EMIS access.

I would like online access.

NHS Organ Donor registration

For more information on organ donation please visit: www.organdonation.nhs.uk

Summary Care Records

This practice has joined the national Summary Care Record programme which enables each patient to have a summary of their key medical information held securely on the NHS central database, known as the NHS Spine. This summary record could be used in an emergency if you needed treatment when access to the medical record held by your GP was not available; for example if you call the doctor out of hours. You will always be asked to give permission for this record to be viewed and you have the right to decline.

Please indicate below whether you would like to have you own Summary Care record by indicating you decision below. A full explanation of each choice follows.

I wish to have a Summary Care record with core data only

I wish to have a Summary Care record with core data and additional important medical information held on your record

I do not wish to have a Summary Care record

A Summary Care record will be created for you from your details held on our GP clinical system and will contain:

Any record we have of your current repeat medication, any acute medication (one-offs e.g. antibiotics) and any recently discontinued medication
Any record we have of adverse reaction to medication
Any record we have of your allergies

A Summary Care Record will be created for you containing the details itemised above in 1 a, b & c plus important additional information you and your GP agree would be useful. (e.g Diagnoses - Asthma, Diabetes etc. Implants - Pacemaker, End of life care etc.) Please discuss this with your GP at your next visit.

A note will be made in your records that you do not wish to have a Summary Care record. Please note that if you attend A&E or if you need emergency treatment when the GP Practice is closed the clinicians treating you may not have access to key information to help them give you the most appropriate treatment.

Signed: *

Date:

Temporary Registration