New Patient Registration

If you would like to register with the practice please use this form.

To register a new patient you will need to live within our practice boundary.

New Patient Registration (With GMS1)

Patient Details

Sex:
Please use the format DD/MM/YYYY
Please use the format email@example.com
Do you consent to being contacted by text message?
Do you consent to being contacted by email?
Are you a carer?

Personal Medical History

Have you ever suffered from: (Tick all that apply)
Do you have difficulty hearing, or need hearing aids or need to lip-read what people say?
Do you have difficulty with memory or ability to concentrate, learn or understand?
Do you have difficulty speaking or using language to communicate or make your needs known?

Medical History of Family (Brothers, sisters, parents, uncles/aunts)

Has any close relative suffered from: (Tick all that apply)

Smoking

Do you smoke?

Drugs and Medicines

Are you taking any drugs, medicines, tablets or contraceptive treatment?

If you take regular medication, please supply us with the repeat order form from your previous surgery if possible.

Are you allergic to any tablets or substances?
Would you like to nominate a pharmacy for your repeat prescriptions to be sent to?

Women

Have you had a hysterectomy?

If you would like a New Patient Check, please book an appointment.

Alcohol Questionnaire

This is one unit of alcohol:

Amount of different types of drink representing one unit of alcohol

And each one of these, is more than one unit:

Amount of different types of drink representing more than one unit of alcoholAmount of different types of drink representing more than one unit of alcohol
How often did you have a drink containing alcohol in the past year? *
How many drinks containing alcohol did you have on a typical day when you are drinking in the past year? *
How often did you have six or more drinks on one occasion in the past year? *

All information will be held electronically in the practice. Thank you for your help.

Summary Care Records (SCR)

The SCR is an electronic record of important patient information, created from GP medical records. It can be seen and used by authorised staff in other areas of the health and care system involved in the patient's direct care.

If you Opt Out NHS Healthcare staff caring for you may not be aware of your current medication, allergies you suffer from and any bad reactions you have had, in order to treat you safely in an emergency.

Do you consent to SCR?

Please complete the Summary Care Record Opt Out form.

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

If you are from abroad

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:

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.

If you need your doctor to dispense medicines and appliances

Not all doctors are authorised to dispense medicines.

NHS Organ Donor Registration

Please tell your family if you want to be an organ donor. Please visit www.organdonation.nhs.uk or call 0300 123 23 23 to register your decision.

NHS Blood Donor Registration

All blood types are needed, especially O negative and B negative. Visit www.blood.co.uk or call 0300 123 23 23.

Zero Tolerance

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Patients should note that appointments with the GP are for ten minutes and only two problems can be discussed during the consultation. Should you have further issues to discuss, you must book another appointment. Please note a referral request, new medication request or private letter are considered as individual problems.

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