New Patient Registration

Patient's Details

Have you checked that you are within our practice boundary? *

Yes

No

Please view our practice boundary.

Please specify:

Gender *

Male

Female

Other

Please specify:

Surname: *

Previous Surnames:

First Name(s) *

Has the patient been known by any other names? *

Yes

No

Please give details of other names:

NHS Number:

If known

Town and Country of birth: *

Home Address: *

Postcode: *

Contact Telephone Number: *

Does the patient speak English? *

Yes

No

Main spoken language (if not English):

What is your ethnic group? *

Which one best describes your White background? *

British

Irish

Irish Traveller or Gypsy

Any other White background

Which one best describes your Mixed background? *

White and Black Caribbean

White and Black African

White and Asian

Any other mixed background

Which one best describes your Asian or Asian British background? *

Which one best describes your Black or Black British background? *

African

Caribbean

Any other Black background

Which best describes your other ethnic group background? *

Arab

Any other ethnic group

Next of Kin

If no next of kin, please leave this blank

Full name:

Contact number:

Relationship to you:

Previous details

Previous address in the UK:

Please include postcode.

Previous Doctor's details:

If you are from abroad

Registering with the NHS for the first time in the UK

Date you came to live in the UK:

Please use this format: DD/MM/YYYY

If you are returning from abroad

Previously been registered with the NHS in the UK

Date you left the UK:

Please use date format DD/MM/YYYY

Date you returned to the UK:

Please use date format DD/MM/YYYY

Disability

Are you registered:

Blind?

Yes

No

Partially Sighted?

Yes

No

Deaf?

Yes

No

Speech Impaired?

Yes

No

Identifying Carers

A carer is anyone who provides unpaid help and support to a family member, friend or neighbour who would have difficulty managing without your help, due to age, physical or mental illness, addiction or disability.

Are you a carer?

Yes

No

Please give a brief description of your role as a carer:

Are you cared for?

Yes

No

Please give a brief description of the care provided:

Supporting Veterans

Have you ever served in the armed forces?

Yes

No

Please state date of enlistment:

Please use date format DD/MM/YYYY

Please state date of leaving:

Please use date format DD/MM/YYYY

Medical History

Do you have any drug allergies?

Yes

No

Please give details:

If you have never been registered with a GP in the UK previously, please give details of any illnesses or hospital treatments:

Medical Conditions (including operations)

Please include dates

Lifestyle

How active are you? ? *

Very Active

Moderately Active

Lightly Active

Inactive

Do you consume alcohol? *

Yes

No

How many units of alcohol do you drink per week?

1 Pint of Beer 4% vol = 2 Units, 1 Bottle of Strong Beer = 3 Units,1 Large glass of Wine = 3 Units, 1 Bottle of Wine = 9 Units. 1 Bottle of Spirits = 30 Units

Did you previously drink alcohol? *

Yes

No

How many units per week did you drink?

When did you stop drinking alcohol?

Please use date format DD/MM/YYYY

Do you smoke? *

Yes

No

How much do you smoke per day?

How much do you smoke per week?

Would you like smoking cessation advice? *

Yes

No

Did you smoke? *

Yes

No

How much did you smoke?

When did you stop smoking?

What did you smoke?

Cigarettes

Cigars

Pipe

Your Summary Care Record and the Sharing of Information

It is important that those caring for you have access to your medical information so they can treat you safely and effectively. Many patients think that if they are seen at a Hospital, by the Ambulance Service or by a District Nurse they can see the notes written by your GP. In most cases this doesn’t happen! Sharing your record for your care can only happen when you tell your GP Surgery that it’s ok.
How do I make my record available to other staff involved in my health care?
Simple. You complete this form and hand it in.

A - Summary Care Record with Additional Information

Anyone registered with a GP practice in England, will have a “Summary Care Record” unless you have chosen not to. It includes: Current medication/ Allergies and details of any previous bad reactions to medicines / Your name, address, date of birth and NHS number.

However, unless you have specifically asked for “Additional Information” to be included, health and care professionals who do not know your medical history may not have the following:
Significant medical history (past and present) / Reason for medication / Anticipatory care information (such as information about the management of long term conditions) / Communication preferences / End of life care information / Immunisations

B - Full Electronic Health Record

Your full electronic health record from your GP Surgery can also be made available to health and social care staff. They will only be able to see this if they are involved in your direct care, and they must still ask for your permission before they look at it. This will also allow your GP Surgery to see what’s recorded about you when you’re seen elsewhere. If there are certain parts of your record that you wish to keep private, your GP Surgery can help with this.

C - Receiving messages via text

You can receive communications from your GP Surgery by letter and phone, however you have to give consent to receive text messages from the GP Surgery to your mobile phone. This includes; appointment reminders, test results, messages relating to your specific health need (e.g. a flu vaccination reminder), general health information that could benefit you, information about emergencies (e.g. winter pressures). Your phone number will not be provided to third parties.

D - Receiving messages via email

You can receive communications from your GP Surgery by letter and phone, however you have to give consent to receive messages from the GP Surgery to your email address. This includes; appointment reminders, test results, messages relating to your specific health need (e.g. a flu vaccination reminder, diabetic management plans), requesting you contact the GP Surgery if they have tried to contact you by telephone, general health information that could benefit you, information about emergencies (e.g. winter pressures)
Your email address will not be provided to third parties.

Your Decision – You can agree to one, two, three or all four

A - Yes, I am happy for additional information to be included in my Summary Care Record, this means healthcare staff treating me can see a summary of my medical history in addition to my medication and allergies

B - Yes, I am happy for my full health record to be shared by my GP Surgery. This will be available to health and social care professionals, who are currently treating me, and have my permission to view it.

C - Yes, I am happy to receive messages from my GP Surgery via text. Messages I receive will only relate to those listed in box C above.

D - Yes, I am happy to receive messages from my GP Surgery via email. Messages I receive will only relate to those listed in box D above.

E - No, I am not happy with any of the above options.

Consent Policies

*

I consent to my GP practice leaving messages on any contact telephone numbers supplied to the practice to identify themselves as my GP practice and to ask me to contact them if I am not available. These messages may be left on answer machines or with other people answering the phone.

I do not consent to my GP practice leaving messages on any contact telephone numbers supplied to the practice

Access to Medical Records Online
It is now a requirement that all newly registered patients have access to their medical records online. It is your choice if you wish to use this online access.

Once you are registered with the surgery you will receive two text messages one with your online username and the other with your online password.

To ensure you will receive these messages please give us an up to date mobile number and sign below to consent to us sending you appropriate SMS messages.

I am happy to receive SMS (Text) messages from Mill Road Surgery.

Signed: *

Date form completed:

*

I confirm that I have completed this form as accurately and honestly as possible and would like to apply to be registered at this practice.