New Patient Registration Form

You should only send this form if you are sure that you are eligible to join this practice. Sending this form will not automatically register you with the surgery. Sending this form does not guarantee or even imply that you will be accepted onto the practice register.

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
Date of Birth
Gender
Address
Email

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

Your previous address in the UK
Address of previous doctor

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 the UK

Supplementary Questions

Are you ordinarily a resident in the UK?

Demographics

Marital Status
Which of the following options best describes you?
Sex and gender identity – Which one of the following best describes how you think of yourself?
Is your gender identity the same as the gender you were given at birth?
Please specify the ethnic group you consider you belong to
What is your main religion?

Communication Needs

Do you speak English?
Do you read English?
Are you a British Sign Language user?

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)

Armed Forces

Have you served in the UK Armed Forces and/or been registered with a Ministry of Defence GP in the UK or overseas?
Do you have access to secure housing?
What is your current immigration status?

Carers

Do you have caring responsibilities?
Do you have a carer?

Emergency Contact

Are they your next of kin?
Do you give us permission to discuss your medical records with them?

About You

Smoking Status

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?
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?

Medical History

Please include dates
Please include dates
Please include dates
We routinely offer HIV screening would you be interested in being screened?
Sight
Hearing

Are you over 75 years old?

The Department of Health has advised that all patients of 75 years and older 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.

Allergies

Do you have any allergies?

Immunisation History

Please include dates

Important Registration Information

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 view your summary record, detailing current medication, allergies and vaccinations.

You will soon 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.

Prescriptions are sent electronically to your nominated pharmacy. We will automatically nominate the pharmacy closest to your post code as part of your registration. If you prefer to use a different chemist please contact the practice to sign up for the Electronic Prescribing Service

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?

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
Your Full Name
Date