New Patient Registration Form

Patient Details

Do you have an NHS Number?(Required)

Select one...YesNo

If you don`t know what's your NHS number, you can find it here

NHS Number(Required)

Title(Required)

Select one...MrMissMrsMsMasterMxDr

Family Name(Required)

Previous Family Name (Optional)

Given Name(Required)

Date of Birth(Required)

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Year202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920

Gender(Required)

Select one...MaleFemaleNot SpecifiedNot Known

Religion (Optional)

This can sometimes help us manage certain health conditions respectfully.

Ethnicity(Required)

Date of Entry to UK(Required)

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Year202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920

Main Language(Required)

Interpreter Required(Required)

Select one...YesNo

Current Address(Required)

Flat Number Number & Street City Postcode

Phone Number(Required)

Email Address(Required)

Previous Address(Required)

Flat Number Number & Street City Postcode

SMS Services(Required)

Do you consent to receive SMS notifications for clinical services?

Select one...YesNo

Email Services(Required)

Do you consent to receive email notifications for clinical services?

Select one...YesNo

Country of Birth(Required)

Select one...EnglandScotlandWalesNorthern IrelandIsle Of ManOutside UK

Place of Birth(Required)

Previous GP(Required)

Type N/A if not applicable

Surgery Name Number & Street City Postcode

Your Next Of Kin

Relationship to you(Required)

Title(Required)

Select one...MrMissMrsMsMasterMxDr

Family Name(Required)

Given Name(Required)

Gender(Required)

Select one...MaleFemaleNot SpecifiedNot Known

Phone Number(Required)

NHS Summary Care Record

You have the choice of what information you would like to share and with whom. Authorised healthcare staff can only view your SCR with your permission. The information shared will solely be used for the benefit of your care.(Required)

Select one...Express consent for medication, allergies and adverse reactions onlyExpress consent for medication, allergies, adverse reactions and additional informationThird Choice Express dissent for Summary Care Record (Opt out) – Patient does not want a summary care record and fully understands the risks involved with this decision. Select this option, if you DO NOT want any information shared with other healthcare professionals involved in your care.

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

Select one...YesNo

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

Select one...YesNo

Would you like to register for online services?(Required)

Select one...YesNo

If you would like your prescriptions to be sent electronically, please provide details of the pharmacy you would like to use

Patient Health Questionnaire

Are you a Carer?(Required)

A Carer is someone, who, without payment, provides help and support to a partner, child, relative, friend or neighbour, who could not manage without their help. This could be due to being elderly, physical or mental illness, addiction or disability. We would be grateful if you could complete the following questions for the Practice Carer’s Register. The register enables the practice to proactively manage carer’s needs with the practice and to consider the provision of services to carers. The practice will also ensure that all patients who are carers are informed of and supported in joining the local carer’s link.

Select one...Yes - Informal / Unpaid CarerYes - Occupational / Paid CarerNo

Are you being cared for?(Required)

Select one...YesNo

Are you registered disabled?(Required)

Select one...YesNo

Do you have a learning disability?(Required)

Select one...YesNo

Have you suffered from any of the following conditions?(Required)

Select one...AsthmaCOPDEpilepsyHeart diseaseHeart attackHeart failureHypertension (High blood pressure)Diabetes Type 1Diabetes Type 2Kidney diseaseStroke or Transient Ischaemic attacksDepression or mental health problemsUnderactive thyroidGlaucomaCancerNone of the above

Please let us know which mental health problem you suffer from or have received treatment for in the past(Required)

Select one...DepressionOCDAnxietyBipolar disorderNone of the above

Please state the year when you were first diagnosed (or approximate date)

Do you have any other mental health problems? If yes, please state these below

Please list any allergies or sensitivities you have including drug allergies below

Add Remove

Please list any immunisations or vaccinations you have had

Add Remove

Upload a copy of children vaccinations

Max. file size: 128 MB.

Any other conditions, operations or hospital admission details

If you are currently under the care of a Hospital or Consultant outside our area, please tell us here

Please record any significant family history of close relatives with medical problems and confirm which relative e.g. mother, father, brother, sister, grandparent

Select one...AsthmaCOPDEpilepsyHeart diseaseStrokeBlood pressureDiabetesKidney diseaseLiver diseaseDepressionThyroidCancerOther

Please give any details if you have ticked any of the above

Current medication

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

Add Remove

Please give the number of hours exercise per week(Required)

How often do you have a drink containing alcohol?(Required)

Select one...NeverMonthly or less2 to 4 times / month2 to 3 times / week4+ times / week

How many units of alcohol do you drink on a typical day when you are drinking?(Required)

Select one...None1 - 23 - 45 - 67 - 910+

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)

Select one...NeverLess than monthlyMonthlyWeeklyDaily or almost daily

What is your smoking status?(Required)

Select one...Never smokedEx-smokerSmoker

Do you use an e-Cigarette?(Required)

Select one...NoEx-userYes

How many cigars / cigarettes or e-cigarettes do you smoke per day?(Required)

Would you like advice / help on quitting?(Required)

Select one...YesNo

Your height(Required)

cm

Your weight(Required)

kg

Have you had a flu vaccination? If yes, please give the date below

For patients aged 65 and over or those with a chronic disease (e.g. asthma or diabetes)

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Have you had a pneumococcal vaccination? If yes, please give the date below

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Consent

By submitting your details you are consenting to providing this information for improving our services to you. The data you supply on this form will be securely stored on our website, which is hosted by a third party. We will retain this information on the website for no longer than 7 calendar days. Your contact details will not be sold or shared with a third party. I understand I can revoke this consent at anytime by contacting the practice. Our privacy policy can be viewed on this website.(Required)

Select one...I agree to the privacy policy

We will contact you to confirm registration within 5 working days, and to book a 'New Patient Health Check' if needed.(Required)

Select one...I have read and accept the above

Date(Required)

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Year202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920

Are you the patient?(Required)

Select one...YesNo

Signature of patient(Required)

Signature on behalf of patient(Required)

Upload Photographic ID

Max. file size: 128 MB.

Upload Proof of Address(Required)

Max. file size: 128 MB.

Name

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