New Patient Registration - Care Home Residents

Before new patients can be taken onto our list, registration forms and a patient history form must be completed and you will have to attend the practice for a simple health check.

If this is your first time registering in the UK you should bring with you proof of your eligibility, for example a document bearing your NHS number or, failing that, your passport.

Before any medication can be issued you must be seen by one of the doctors or nurse practitioners.

Title

First names

Surnames

Previous surnames

Date of Birth

Gender

Town and country of birth

NHS Number

Address

Telephone Number

It is your responsibility to keep us updated with any changes to your telephone number, email & postal address. We may contact you with appointment details, test results or health campaigns

Next Of Kin Details

Next of Kin Name

Next of Kin Telephone:

Relationship to you

Family Registered With Us

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

NHS Organ Donor registration

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.

I 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 the boxes that apply.

Any of my organs and tissue or

Kidneys

Heart

Liver

Corneas

Lungs

Pancreas

NHS Blood Donor registration

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

Have you given blood in the last 3 years

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

Registration Details

Would you like temporary or permanent registration?

Ethnicity

If other please provide details

Religion

If other please provide details

Communication Needs

What is your main spoken language?

Do you need an interpreter?

Do you have any communication needs?

Your communication needs

Allergies

Please record any allergies or sensitivities below

Current Medication

Are you on regular medications?

Please check and include as much information about your current medication below. Please give us your previous repeat medication list if possible and a medication review appointment may be needed

Privacy Protection

Information submitted through secure forms is used only for the purposes of processing your request. We may be in touch with you in relation to the information submitted.

All Information submitted through secure forms is secured with a private key and is accessed over a secure connection by nominated staff. We have a strict confidentiality policy.

This information is not shared with any third party organisations.

This information is retained for up to 28 days.

I consent to my information being used for the purposes described above and wish to submit this online form to Parkside Medical Centre, Boston • Tawney Street, Boston, Lincolnshire, PE21 6PF.

Learn more about our Privacy Policy and Terms of Use. Should you have any concerns about sending your personal details using the web, please use one of the alternative methods offered by our organisation.

Key Information

New Patient Registration - Care Home Residents

Privacy Protection