New Patient Registration - Adults
Title
Required
First names
Required
Surnames
Required
Previous surnames
Required
Date of Birth
Required
Date
Gender
Which of the following best describes how you think of yourself?
None
Non-binary
Male
Female
Prefer to not say
Unable to answer
Is your gender the same as the sex you were assigned at birth?
Required
Yes
No
Prefer not to say
Town and country of birth
Required
NHS Number
Address
Required
Home Telephone
Work Telephone
Mobile Telephone (Please repeat home number if not available)
Required
Do you consent to being contacted by SMS on this number
Yes
No
Email
Do you consent to being contacted by email at this address
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
Required
Next of Kin Telephone
Required
Relationship to you
Required
Family Registered With Us
_________________________________________________
Please help us trace your previous medical records by providing the following information
Your previous address in UK (please state NA if not applicable)
Required
Name of previous GP practice while at that address (Please state NA if not applicable)
Required
Address of previous GP practice (Please state NA if not applicable)
Required
_______________________________________________
If you are from abroad
Please add birthdate as entry date if not new to country
Your first UK address where registered with a GP (Please state NA if not applicable)
Required
Date you first came to live in UK
Required
Date
_______________________________________________
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:
None
Regular
Reservist
Veteran
Family Member (Spouse, Civil partner, Service Child)
Address before enlisting
Service or Personnel number
Enlistment date
Date
Discharge date: (if applicable)
Date
______________________________________________
NHS Organ Donor registration
You will automatically be considered that you agree to become an organ donor when you die unless you are under 18, have opted out or are in an excluded group.
For further information, please see: www.organdonation.nhs.uk
_________________________________________
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.
Yes
No
Have you given blood in the last 3 years
Yes
No
My preferred address for donation is: (only if different from above, e.g. your place of work)
___________________________________________________
PATIENT DECLARATION 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, otherwise you may be charged for your treatment. Even if you have to pay for a service, you will always be provided with any immediately necessary or urgent treatment, regardless of advance payment. The information you give on this form will be used to assist in identifying your chargeable status, and may be shared, including with NHS secondary care organisations (e.g. hospitals) and NHS Digital, for the purposes of validation, invoicing and cost recovery. You may be contacted on behalf of the NHS to confirm any details you have provided.
Please select one of the following statements
Required
None
I understand that I may need to pay for NHS treatment outside of the GP practice
I understand I have a valid exemption from paying for NHS treatment outside of the GP practice. This includes for example, an EHIC, or payment of the Immigration Health Charge (“the Surcharge”), when accompanied by a valid visa. I can provide documents to
I do not know my chargeable status
____________________________________________________
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.
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.
Do you have a non-UK EHIC or PRC?
Required
Yes
No
If yes, please enter details from your EHIC or PRC below
Name
Given Names
Date of Birth
Date
Personal Identification Number
Identification number of the institution
Expiry Date
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).
Yes
No
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.
______________________________________________
Registration Details
Ethnicity
Required
White (UK)
White (Irish)
White( Other)
Black Caribbean
Black African
Black Other
Bangladeshi
Indian
Pakistani
Arabic
Chinese
Other
If other please provide details
Religion
Required
C of E
Catholic
Other Christian
Buddhist
Hindu
Muslim
Sikh
Jewish
Jehovah's Witness
No religion
Other
If other please provide details
_____________________________________________
Communication Needs
What is your main spoken language?
Required
Do you need an interpreter?
Required
Yes
No
Do you have any communication needs?
Required
Yes
No
If Yes please specify your communication needs below
Hearing aid
Lip reading
Large print
Braille
British sign language
Makaton sign language
Guide dog
Do you have a Learning Disability?
Required
Yes
No
If Yes please request a Learning Disability Screening Tool form
________________________________________________
Carer Details
Are you a carer?
Required
Yes- Informal/ Unpaid Carer
Yes- Occupational/ Paid Carer
No
If yes please provide the details below. Only add carer’s details if they give their consent to have these details stored on your medical record
Carer's name
Telephone
Relationship to you
__________________________________________
Medical History
Have you suffered from any of the following conditions?
No to All
Yes ( Please select the condition/s below)
Asthma
COPD
Epilepsy
Heart Disease
Heart Failure
High Blood Pressure
Diabetes
Kidney Disease
Stroke
Depression
Underactive Thyroid
Cancer
Any other conditions, operations or hospital admission details. If you selected Cancer above please provide the type of cancer here.
If you are currently under the care of a Hospital or Consultant outside our area, please tell us here
_______________________________________________
Family History
Please record any significant family history of close relatives with medical problems and confirm which relative e.g. mother, father, brother, sister, grandparent
Asthma
COPD
Epilepsy
Heart Disease
Stroke
Blood Pressure
Diabetes
Kidney Disease
Liver Disease
Depression
Thyroid
Cancer
Other
_______________________________________________
Allergies
Please record any allergies or sensitivities below
____________________________________________
Current Medication
Are you on regular medications?
Required
Yes
No
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
Are any of your regular medications prescribed by another Health Care Provider (i.e. from abroad)
Yes No
If yes, please list the medications below
_______________________________________________
Alcohol
Please answer the following questions which are validated as screening tools for alcohol use
How often do you have a drink containing alcohol?
Required
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?
Required
0
1-2
3-4
5-6
7-9
10+
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?
Required
Never
Less than monthly
Monthly
Weekly
Daily or almost daily
How often during the last year have you found that you were not able to stop drinking once you had started?
Required
Never
Less than monthly
Monthly
Weekly
Daily or almost daily
How often during the last year have you failed to do what was normally expected from you because of your drinking?
Required
Never
less than monthly
Monthly
Weekly
Daily or almost daily
How often during the last year have you needed an alcoholic drink in the morning to get yourself going after a heavy drinking session?
Required
Never
Less than monthly
Monthly
weekly
Daily or almost daily
How often during the last year have you had a feeling of guilt or remorse after drinking?
Required
Never
Less than monthly
Monthly
Weekly
Daily or almost daily
How often during the last year have you been unable to remember what happened the night before because you had been drinking?
Required
Never
Less than monthly
Monthly
Weekly
Daily or almost daily
Have you or somebody else been injured as a result of your drinking?
Required
No
Yes, but not in last year
Yes, during last year
Has a relative or friend, doctor or other health worker been concerned about your drinking or suggested that you cut down?
Required
No
Yes, but not in last year
Yes, during last year
_________________________________________________
Smoking
Do you smoke?
Required
Never smoked
Ex-smoker
Yes
Do you use an e-Cigarette?
Required
No
Ex-user
Yes
How many cigarettes did/do you smoke a day?
Less than one
1-9
10-19
20-39
40+
Would you like help to quit smoking?
Yes
No
Height
Weight
Blood Pressure
________________________________________________
Women Only
Do you use any contraception?
Yes
No
Do you have a coil or implant in situ?
Yes
No
If yes, date inserted:
Are you currently pregnant or think you may be?
Yes
No
If yes, What is your expected due date
_____________________________________________
Students Only
Students are at risk of certain infections including mumps, meningitis and sexually transmitted infections, as well as mental health issues including stress, anxiety and depression. Please see www.nhs.uk/Livewell/Studenthealth
I am less than 24 years old and have had two doses of the MMR Vaccination
Yes
No
Unsure
__________________________________________________
Further Details
Electronic Prescribing
Patient Participation Group
We are committed to improving the services we provide. The Patient Participation Group is a mechanism for us to gain valuable feedback from our patients about their experiences, views and ideas for improving our services.
Would you like to be involved in our Patient Participation Group?
Yes
No
________________________________________________
If you would like your prescriptions to go electronically, please provide details of the pharmacy you would like to use:
Sharing Your Health Record
Do you consent to your GP Practice sharing your health record with other organisations who care for you?
Yes ( recommended option)
No, except in an emergency
No, never( not recommended, please discuss this with your GP before selecting this option)
Do you consent to your GP Practice viewing your health record from other organisations that care for you?
Yes ( recommended option)
No
_________________________________________________
Your Summary Care Record (SCR)
Do you consent to having an Enhanced Summary Care Record with Additional Information?
Yes (recommended option)
No
_____________________________________________________
Online Access To Your Health Record
I wish to have online access to: (Please select all that apply)
View & book appointments
View & request medication
Access my coded medical record (contains any medical codes that have been recorded)
Access my full medical record (contains medical codes and any free text that has been recorded)
Access my Summary Care Record
Complete online questionnaires
I wish to access my medical record & understand & agree with each statement:
Required
I have read and understood the ‘Important Information’ section in the download
I will be responsible for the security of the information that I see or download
If I choose to share my information with anyone else, this is at my own risk
I will contact the practice as soon as possible if I suspect that my account has been accessed by someone without my agreement
If I see information in my record that it not about me, or is inaccurate I will log out immediately and contact the practice as soon as possible
The practice will be in contact to collect ID and registrations can take up for 5 working days from receipt of ID, and the registration will not be processed without ID unless prior approval has been granted
I am aware that the registration won’t be accepted until identification is provided to the practice
Yes
No