New Patient Registration

Title

First Name(s)

Surname

Previous surname/s

Date of Birth

NHS Number

Are you:

Town and country of birth

Home address

Postcode

Mobile:

Home phone

E-mail address

(By giving us this information you are happy for us to email information to you relating to your care)

Do you consent to us sending you text messages relating to your care e.g. appointment reminders and when we need you to contact the surgery?

Do you consent to us leaving messages on your answer phone?

Do you consent to us informing another member of the household that the surgery has phoned?

What is your preferred method of contact?

Next Of Kin details:

Name:

Contact Number:

Relationship:

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

Your previous address in UK

Name of previous GP practice while at that address

Address of previous GP practice

If you are from abroad

Your first UK address where registered with a GP

If previously resident in UK, date of leaving:

Date you first came to live in 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:

Address before enlisting:

Postcode

Service or Personnel number

Enlistment date

Discharge date (if applicable):

Footnote: These questions are optional and your answers will not affect your entitlement to register or receive services from the NHS but may improve access to some NHS priority and service charities services.

If you need your doctor to dispense medicines and appliances*

* Not all doctors are authorised to dispense medicines

I live more than 1.6km in a straight line from the nearest chemist

I would have serious difficulty in getting them from a chemist

NHS Organ Donor registration

want to register my details on the NHS Organ Donor Register as someone whose organs/tissue may be used for transplantation after my death. Please select all the options that apply.

Any of my organs and tissue or

Kidneys

Heart

Liver

Corneas

Lungs

Pancreas

Please tell your family you want to be an organ donor. If you do not want to be an organ donor, please visit www.organdonation.nhs.uk or call 0300 123 23 23 to register your decision.

NHS Blood Donor registration

I would like to join the NHS Blood Donor Register as someone who may be contacted and would be prepared to donate blood.

I have given blood in the last 3 years

My preferred address for donation is: (only if different from above, e.g. your place of work)

Postcode:

All blood types are needed, especially O negative and B negative. Visit www.blood.co.uk or call 0300 123 23 23.

For all patients who are not ordinarily resident in the UK

Anybody in England can register with a GP practice and receive free medical care from that practice.

However, if you are not ‘ordinarily resident’ in the UK you may have to pay for NHS treatment outside of the GP practice. Being ordinarily resident broadly means living lawfully in the UK on a properly settled basis for the time being. In most cases, nationals of countries outside the European Economic Area must also have the status of ‘indefinite leave to remain’ in the UK.

Some services, such as diagnostic tests of suspected infectious diseases and any treatment of those diseases are free of charge to all people, while some groups who are not ordinarily resident here are exempt from all treatment charges.

More information on ordinary residence, exemptions and paying for NHS services can be found in the Visitor and Migrant patient leaflet, available from your GP practice.

You may be asked to provide proof of entitlement in order to receive free NHS treatment outside of the GP practice,

Please select one of the following options:

I declare that the information I give on this form is correct and complete. I understand that if it is not correct, appropriate action may be taken against me.

A parent/guardian should complete the form on behalf of a child under 16.

Your Name

Relationship to patient

NON-UK European Health Insurance Card (EHIC), Provisional Replacement Certificate (Prc) Details And S1 Forms

Complete this section if you live in another EEA country, or have moved to the UK to study or retire, or if you live in the UK but work in another EEA member state. Do not complete this section if you have an EHIC issued by the UK.

Do you have a non-UK EHIC or PRC?

If yes, please enter details from your EHIC or PRC below:

If you are visiting from another EEA country and do not hold a current EHIC (or Provisional Replacement Certificate (PRC))/S1, you may be billed for the cost of any treatment received outside of the GP practice, including at a hospital.

Country Code:

Name

Given Names

Date of Birth

Personal Identification Number

Identification number of the card

Expiry Date

PRC validity period - From:

PRC validity period - To:

Do you have an S1 (e.g. you are retiring to the UK or you have been posted here by your employer for work or you live in the UK but work in another EEA member state). Please give your S1 form to the practice staff.

How will your EHIC/PRC/S1 data be used? By using your EHIC or PRC for NHS treatment costs your EHIC or PRC data and GP appointment data will be shared with NHS secondary care (hospitals) and NHS Digital solely for the purposes of cost recovery. Your clinical data will not be shared in the cost recovery process.

Your EHIC, PRC or S1 information will be shared with The Department for Work and Pensions for the purpose of recovering your NHS costs from your home country.

Prescriptions: – to be ordered online

Prescriptions are sent electronically to your nominated pharmacy

Please tell us which pharmacy you would like to use:

Carer Status

Please let us know if you are the main person responsible for looking after and caring for someone who is dependent upon you

Are you a Carer?

Do you have a Carer?

If yes, please provide the following details for your Carer:

Carer's Name

Contact details:

Children Under 12

Do you wish to nominate another person who has your permission to give consent for urgent medical treatment in an emergency? E.g. childminder, grandparent or other relative etc

Nominated person's name:

Contact Number

Relationship:

Does your child have a social worker?

If Yes please could you provide us with their details:

Social Worker's name:

Contact Number

Ethnic Origin:

In accordance with new Public Health requirements we require the following information.

Please state your first language:

Please indicate your ethnic origin by selecting one option from the list below

Ethnic category not stated, please specify

Communication Needs

Do you have any specific information or communication needs? If so, please specify how we can meet these for you (e.g. large print, Braille, easy read communications)

If you do have any specific information or communication needs, please confirm if you consent to us sharing these with other NHS or social care professionals who provide care for you, by ticking the appropriate box below:

Your Health

Smoking Information

Do you smoke?

If Yes how many per day?

Have you ever smoked?

If Yes when did you stop?

Alcohol Intake Information:

How often do you have a drink containing alcohol?

How many units of alcohol do you drink on a typical day when you are drinking?

How often have you had 6 or more units if female, or 8 or more if male, on a single occasion in the last year?

How often during the last year have you found that you were not able to stop drinking once you had started?

How often during the last year have you failed to do what was normally expected from you because of your drinking?

How often during the last year have you needed an alcoholic drink in the morning to get yourself going after a heavy drinking session?

How often during the last year have you had a feeling of guilt or remorse after drinking?

How often during the last year have you been unable to remember what happened the night before because you had been drinking?

Have you or somebody else been injured as a result of your drinking?

Has a relative or friend, doctor or other health worker been concerned about your drinking or suggested that you cut down?

We will receive your full medical notes from your previous GP practice but in the meantime is there anything you would like us to know about your recent health?

Do you need regular GP reviews?

If Yes please could you please give brief details:

Are you currently under the care of any hospital consultants or are waiting to be referred?

If Yes please could you give the hospital department and any other brief details:

Are you aware of any pending follow-up tests?

Is there anything in your recent medical history that you feel should be monitored / followed up?

If Yes please could you please give brief details:

Are you taking any repeat medications?

If Yes please could you provide us with your repeat prescription ‘tick list’ from your previous surgery, if you have one.

Have you ever had any of the following?

Allergies