New Patient Registration

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Patient's Details

Information we need to register you with the practice
Please note all fields marked with a * are mandatory for your registration

 
By supplying us with your email and mobile you agree to us contacting regarding your health
 
Ethnicity
Please describe in your own words your ethnic background
 
 
Emergency Contact
 
Previous Details
Please include postcode
If you are from abroad
Please use this date format: DD/MM/YYYY
If you are returning from abroad

Previously been registered with the NHS in the UK

Please use this date format: DD/MM/YYYY
Please use this date format: DD/MM/YYYY
Were you ever registered with an Armed Forces GP

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

European Economic Area (EEA) Country

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

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.

Please enter the details from your EHIC or PRC below.

S1 Form

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.

Carers
i.e. do you have a paid or voluntary carer (ie friend/relative) who helps you live your day to day life
i.e. do you look after a friend or relative who is sick or disabled or has a significant mental problem or special needs (including a parent or guardian of a child)
 
 
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Adult Females
Please use this date format: DD/MM/YYYY.
 
Immunisation History
Please include dates.
Medical History
Please include dates.
Please include dates.
Have any close family members (parents, siblings, aunts, uncles and grandparents) suffered from any of the following illnesses, Please include dates.

HIV:All new patients above the age of 16 are eligible to have a HIV blood test. If you would like this please request a blood test form from reception

Chlamydia: If you are sexually active you can do a self-taken Chlamydia test. These are available in the toilets of the surgery and can be handed in to reception.

Lifestyle
 
 
Your Personal Alcohol Consumption

information on what 1 unit of alcohol looks like

What does 1 unit of alcohol look like?

  • Cider (218ml, ABV 4.5%)
  • Wine (76ml, ABV 13%)
  • Whisky (25ml, ABV 40%)
  • Beer (250ml, ABV 4%)
  • Alcopop (220ml, ABV 4%)

If you are unsure about your alcohol consumption please visit the NHS Website

ALCOHOL UNIT ADVICE
 

Audit Score Result

you have a score of 

If you are drinking less than 14 units of alcohol per week, then your drinking is within the UK Chief Medical Officers' low risk drinking guidelines.

But if you are drinking regularly at or above the low risk guidelines of 14 units a week, or, you are drinking six or more units - if you are female - or eight or more units - if you are male - in one single session (binge drinking), please consider the increased serious risks to your health being caused by your current drinking pattern.

 
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Patient online access

We encourage all patients to obtain online access to their records.

This will allow you to use patient apps like the NHS App which will allow you to: book appointments, make online consultations with us for simple requests using eConsults, request repeat prescriptions and look up information on your medical records like immunisations, blood test and other results with comments  as well as update donation preferances.

For us to be able to enable this functionality we need to confirm your identity so please ensure you upload your photo identification and proof of address as requested at the end of this form (page 4).

Summary Care Record

Summary Care Record (SCR)

The Summary Care Record (SCR) system is designed to help both your GP and any emergency staff you contact when the surgery is closed to treat your health needs more efficiently.

Your information will be shared between your GP practice, our local hospital and Out Of Hours service. This will enable your GP surgery to access results and any visits you have at the hospital quickly and efficiently, but it also means that if you have an emergency and contact the Out Of Hours service or visit A&E they will have access to your current medications as well as allergies and are better able to treat you.

If you do not return this form, a Summary Care Record will be created for you based on implied consent

NHS Organ Donor Registration

NHS Organ Donor Registration

REGISTER WITH NHS

 At this stage we will be mainly noting your preferences internally. However, if contacted by the transplant service we would notify them of your choices and therefore by ticking a box you are confirming your agreement to the organ/tissue donation.

Please leave this section blank if you do not wish to register you preferences

NHS Blood Donor Registration

NHS Blood Donor registration

REGISTER

At this stage we will be mainly noting your preferences internally. However, if contacted by the blood & transplant service we would notify them of your choices and therefore by ticking a box you are confirming your agreement to the organ/tissue donation.

Please leave this section blank if you do not wish to register.

Patient Participation Group
You can withdraw consent in writing at any time
 
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Identification Upload

Patient Identification

To fully register you at the practice, we need Two forms of Acceptable ID (if not possible, please let us know).

We will not store these documents and we will securely delete / destroy them after our initial verification.

OPTIONAL: Photo of your face to add to your records to help us identify you (if you agree)

Acceptable Identification: Photo Driving License, Passport, Tenancy agreement, Mortgage statement, Bank statement, Utility bill (date within the past 3 months) etc.

Signature

Privacy Consent

This form collects personal and medical information about you. We use this information to allow the practice team to contact you. Please read our Privacy Policy to discover how we protect and manage your submitted data.

 
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