New Patient Registration Form (GSM1 + Health Q’s)

If you are new to the area and wish to register with the Practice, please complete the form below – each person registering will need to complete a form.

Personal Details

Name

Title First(s) Last

Previous Surname Optional

Address

Street Address Address Line 2 City Postcode

Main Contact Number

Alternative Contact Number Optional

Enter Email Optional Confirm Email Optional

NHS Number Optional

Date of Birth

Day

Month

Year

Town and Country of Birth

Ethnicity

Gender (at birth)

Female

Male

Which of the following gender identities best describes how you think of yourself?

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

Are you from abroad?

Yes

Your previous address in the UK

Street Address Address Line 2 City Postcode

Name of doctor while at that address Optional

Address of previous doctor

Street Address Address Line 2 City Postcode

Your first UK address where registered with a GP

Street Address Address Line 2 City Postcode

If previously resident in UK, date of leaving

Day Optional

Month Optional

Year Optional

Date you first came to live in the UK

Day Optional

Month Optional

Year Optional

Asylum Status

Are you seeking asylum in the UK?

Yes

Please present your ARC card or a letter from the Home Office at the surgery.

Max. file size: 50 MB.

Armed Forces

Are you, or have you ever served in the UK Armed Forces?

Yes

What was your enlistment date?

Day

Month

Year

If applicable, what was your discharge date?

Day Optional

Month Optional

Year Optional

Communication Needs

Do you speak English?

Yes

What is your main spoken language?

Do you require an interpreter?

Yes

Are you a British Sign Language user?

Yes

Carers

Are you a carer?

Yes

Do you have a carer?

Yes

Carer's Name

First Last

Carer's Contact Number

Do you give us permission to discuss your medical records and appointments with your carer?

Yes

Next of Kin Details

Full Name

First Last

Relationship to you

Contact Number

Do you give us permission to discuss your medical records and appointments with your next of kin?

Yes

Medical History and Lifestyle Questions

Are you currently taking any medication?

Yes

Please list any medication you are currently taking.

Who is your nominated pharmacy for electronic prescribing?

Please describe your eyesight:

Good

Poor

Registered Blind

Please describe your hearing:

Good

Poor

Partially Deaf

Deaf

Do you have any allergies?

Yes

Please specify

Do you use a wheelchair to mobilise?

Yes

Are you housebound?

Yes

Have you ever been diagnosed with cancer?

Yes

Please indicate your diagnosis, with dates if possible. Optional

Do you have a learning difficulty?

Yes

Please indicate your diagnosis with dates if possible. Optional

Have you had any serious Illnesses?

Yes

Please indicate your diagnosis with dates if possible. Optional

Have you had any major operations?

Yes

Please list these with dates if possible. Optional

Do you have a family history of any illnesses?

Yes

Please list these with dates if possible. Optional

Do you have an impairment, health condition or learning difference that is not listed above?

Yes

Please indicate your diagnosis, with dates if possible. Optional

Height

(cm)

Weight

(kg)

Alcohol Consumption

This is one unit of alcohol:

• Half pint of regular Beer/Lager/Cider

• 1 small glass of wine

• single measure of spirits

• 1 small glass of sherry

Each of these is more than one unit:

• Pint of regular Beer/Lager/Cider (2 Units)

• Pint of Premium Beer/Lager/Cider (3 Units)

• Alcopop or can/bottle of regular Lager (1.5 Units)

• Can of Premium Lager/Strong Beer (2 Units)

• Can of super strength lager (4 Units)

• Glass of wine (2 Units)

• Bottle of wine (9 Units)

Think about your regular drinking habits; do you consider yourself to be a:

If you feel like you need advice or support regarding your alcohol intake, call DRINKLINE on 0300 123 1110 for free confidential advice or visit www.nhs.uk/live-well/alcohol-advice/alcohol-support.

You can also visit/contact the surgery for advice.

What is your smoking Status?

If you are a current smoker’, how many cigarettes do you smoke per day?

If you roll your own cigarettes, how many grams of tobacco do you smoke per week? Optional

For help with stopping smoking, call the SMOKEFREE NATIONAL HELPINE on 0300 123 1044 or visit www.nhs.uk/better-health/quit-smoking/find-your-local-stop-smoking-service/.

You can also visit/contact the surgery for advice.

Contact Preferences

The practice will contact you via telephone and by post where required.

Do you also consent to being contacted by text message?

Yes

Do you also consent to being contacted by email?

Yes

Online Access

For anyone aged 16 and over, we offer online services for appointment booking and repeat prescription ordering. This is the quickest and easiest way to order your medication. Once registered, you will also be able to book appointments and view your medical record. If you wish to register, please give your consent below; you will receive an email from the practice with your log in details. These are confidential: It is your responsibility to ensure they can be received securely by email.

Do you consent to online access being set up on registration by the practice?

Yes

Please confirm your email address

Enter Email Confirm Email

Summary Care Record

This record will contain summary information about any medicines you are taking, allergies you suffer from and any bad reactions to medicines you have had to ensure those caring for you have enough information to treat you safely.

Your Summary Care Record will be available to authorised healthcare staff providing you with care anywhere in England, but they will ask your permission before they look at it. This means that if you have an accident or become ill away from home, healthcare staff treating you will have immediate access to important information about your health.

Do you consent to having a Summary Care Record?

Yes

Your Medical Information – Sharing Your Data

Under the General Data Protection Regulations (GDPR), we have a responsibility to keep your medical records confidential. We need your consent to share this with other authorised health professionals involved in your care or in planning your care. You can find more information on the website at www.nhs.uk/your-nhs-data-matters.

Please see the privacy notice on our website for more information on how your data is held and used by the practice.

There are very strict rules on how this data can and cannot be used, and you have clear data rights. We are committed to keeping patient information safe and will always be clear on how it is used.

You can choose whether your confidential patient information is used for research and planning.

If you do not wish your information to be used in this way, please opt-out by visiting NHS: Your Data Matters or by calling 0300 303 5678. The practice is unable to record this for you.

NHS Organ Donor Registration

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

NHS Blood Donor Registration

If you would like to join the NHS Blood Donor Register, please visit www.blood.co.uk or call direct on 0300 123 2323.

Signature

Please upload your two forms of Identification (one photographic and one proof of address)

Drop files here or

Max. file size: 50 MB, Max. files: 2.

Declaration

I certify that the information I have provided is correct and consent to my personal and medical information being used as stated above.

Your Full Name

Date

Day

Month

Year

Signature