NEW PATIENTS

Please check that you are in our catchment area – if you are not, the form will not be processed.

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

Title

NHS Number

Find my NHS Number. Required if you have previously been registered with a GP in the UK, otherwise enter ‘000-000-0000’.

First Names

Surname

Previous Surname Optional

Date of Birth

Gender

Male (including Trans Men)

Female (including Trans Women)

Non Binary

Other

Other Gender (Please State)

Occupation Optional

First Spoken Language

Town and Country of Birth

Address

Street Address Address Line 2 City Postcode

Mobile Phone Number

Home Phone Number Optional

Work Phone Number Optional

Can we contact you by text?

Enter Email Confirm Email

Can we contact you by email?

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

Your previous address in the UK

Street Address Optional Address Line 2 Optional City Optional Postcode Optional

Name of doctor while at that address Optional

Address of previous doctor

Street Address Optional Address Line 2 Optional City Optional Post Code Optional

If you are from abroad

Registering with the NHS for the first time in the UK

Are you from abroad and registering with the NHS for the first time in the UK?

Yes Optional

No Optional

Date you first came to live in the UK

Are you returning from abroad?

Yes Optional

No Optional

Previously been registered with the NHS in the UK

Date you left the UK

Date you returned to the UK

Supplementary Questions

UK Residency

I am not ordinarily a resident in the UK Optional

European Economic Area (EEA) Country

For a list of EEA countries visit: www.gov.uk/eu-eea

Do you live in another EEA country, or have moved to the UK to study or retire, or live in the UK but work in another EEA member state?

Yes Optional

No Optional

Do you have a non-UK European Health Insurance Card (EHIC) or a Provisional Replacement Certificate (PRC) ?

Yes Optional

No Optional

f 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.

Please enter the details from your EHIC or PRC below.

Country Code

3. Name

4. Given Names

5. Date of Birth

6. Personal Identification Number

7. Identification number of the institution

8. Identification number of the card

9. Expiry Date

PRC validity period from

PRC validity period to

Do you have an S1 Form?

I have an S1 form Optional

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.

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.

Demographics

Marital Status

Single, never married Optional

Married Optional

Civil Partnership Optional

Divorced Optional

Widowed Optional

Separated Optional

Which of the following options best describes you?

Heterosexual or Straight Optional

Gay or Lesbian Optional

Bisexual Optional

Prefer not to say Optional

In another way Optional

What is your main religion?

No religion Optional

Christian (including Church of England, Catholic, Protestant, and all other Christian denominations) Optional

Buddhist Optional

Hindu Optional

Jewish Optional

Muslim Optional

Sikh Optional

Other religion Optional

Ethnicity

Do you speak English?

Yes

Do you read English?

Yes

What is your main spoken language?

Disability

Do you have an impairment, health condition or learning difference that has a substantial or long term (over a year) impact on your ability to carry out day to day activities? (Tick all that apply)

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) Optional

Armed Forces

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 do not wish to tell us you were in the armed forces simply answer ‘No’ to the question ‘Were you ever registered with an Armed Forces GP’.

Have you served in the UK Armed Forces and/or been registered with a Ministry of Defence GP in the UK or overseas?

Yes

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 (Spouse, Civil Partner, Service Child)

Address before enlisting

Street Address Address Line 2 City Post Code Country

Service or Personnel number

Enlistment Date

Discharge date (if applicable)

Carers

Do you have a carer?

Yes

Are you a carer for someone?

Yes

Carer Name Optional

Carer Telephone Number Optional

Carer's Address

Street Address Optional Address Line 2 Optional City Optional Post Code Optional Country Optional

Do you give us permission to discuss your medical record with your carer?

Yes Optional

No Optional

Emergency Contact

Full Name

Relationship to you

Contact Number

Are they your next of kin?

Yes

Do you give us permission to discuss your medical records with them?

Yes

About You

Height

Weight

Smoking Status

Current Smoker

Ex Smoker

Never Smoked

Tell us more about your smoking history (include when you gave up)

What do you smoke?

e.g. Cigarettes, Vape, Cigars

How many do you smoke per day?

Are you interested in advice on how to quit?

Yes

Please state how much exercise and what type of exercise you do per week Optional

Alcohol Consumption

This is one unit of alcohol:

Half pint of regular Beer/Lager/Cider
1 small glass of wine
1 single measure of spirits
1 single measure of aperitifs
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)

How often do you have a drink containing alcohol?

Never

Monthly or less

2-4 times per month

2-3 times per week

4+ times per week

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?

Never

Less than monthly

Monthly

Weekly

Daily or almost daily

Do you have any significant family history we should be aware of? Optional

Medical History

Major Illnesses Optional

Please include dates

Past Operations Optional

Please include dates

Family History Illnesses Optional

Please include dates

Current Medication Optional

Nominated Pharmacy Optional

Enter the name of the pharmacy where you collect your medication (if applicable)

Last Blood Pressure Reading (if known) Optional

Enter Systolic BP value over Diastolic BP value. For example: 120 over 80

Have you had a Smear Test?

Yes

Please give the date of your last smear test

What was the result?

Normal

Abnormal

Where was this smear test taken?

Enter name and address of the clinic

Sight

Good

Poor

Registered Blind

Hearing

Good

Poor

Partially Deaf

Deaf

Allergies

Do you have any allergies?

Yes

Please specify what you are allergic to, what happens and when you had your first reaction

Immunisation History

Please list any immunisations/vaccinations you have had Optional

Please include dates

Your Health Record

What is your health record?

Your health record contains all the clinical information about the care you receive. When you need medical assistance it is essential that clinicians can securely access your health record. This allows them to have the necessary information about your medical background to help them identify the best way to help you. This information may include your medical history, medications and allergies.

Why is sharing important?

Health records about you can be held in various places, including your GP practice and any hospital where you have had treatment. Sharing your health record will ensure you receive the best possible care and treatment wherever you are and whenever you need it. Choosing not to share your health record could have an impact on the future care and treatment you receive.

To find out more see Your Health Record on theNHS website

Do you consent to your GP Practice sharing your health record with other organisations who care for you?

Yes (recommended option)

No, never

Do you consent to your GP Practice viewing your health record from other organisations that care for you?

Yes (recommended option)

No, never

Summary Care Record (SCR)

What is your Summary Care Record?

Your Summary Care Record contains basic information including your contact details, NHS number, medications and allergies. This can be viewed by GP practices, Hospitals and the Emergency Services. If you do not want a Summary Care Record, please ask your GP practice for the appropriate opt out form. With your consent, additional information can be added to create an Enhanced Summary Care Record. This could include your care plans which will help ensure that you receive the appropriate care in the future.

For further information seeSummary Care Record on the NHS website

Do you consent to having a Summary Care Record?

Yes (recommended option)

Do you consent to having an Enhanced Summary Care Record with Additional Information?

Yes (recommended option)

Patient Participation

Would you like to receive occasional communications from our Patient Participation Group?

Yes

Named GP

The Department of Health has advised that all patients have a named and accountable GP to oversee their care. Please ask the name of the GP assigned to oversee your care. Please note this does not prevent you from seeing the GP of your choice.

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.

The NHS wants to make sure you and your family has the best care now and in the future. Your health and adult social care information supports your individual care. It also helps us to research, plan and improve health and care services in England.

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 or not 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 as someone who may be contacted and would be prepared to donate blood, please visit their website on: www.blood.co.uk or call direct on 03001232323

What happens to my information?

Personal and medical information about patients registered at this practice are primarily kept electronically, although some is kept in paper form. Some information will be sent to hospital consultants and other health professionals to whom you are referred by your GP in order to provide continued healthcare and obtain treatment for you.

We sometimes use accredited suppliers for our communication with you, for example when we send recall letters for review clinics or medication reviews. All suppliers we use are checked carefully to ensure they comply with strict confidentiality protocols.

To ensure the security of all patient information, all staff that has access to your records is covered by confidentiality clauses in their contracts and the Data Protection Act and the Freedom of Information Act. Our guiding principle is that we hold your records in strict confidence.

Signature

Declaration

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

Signature

Your Full Name

Date

Phone Optional

This field is for validation purposes and should be left unchanged.