NewPatientRegistration

New Patient Registration

We're sorry, but in any any big organisation like the Health Service, there's a few forms that have to be gone through.

If you've decided you'd like to register with us, there are a couple of forms we'd need completing.

You could either :-

come to the surgery and collect the forms from our hatch during normal opening hours- if necessary, our Reception Staff will be delighted to help you complete the forms-

or

complete this On line form.

You should do this NOW, ideally well before you need to use our services. Please understand that it may well take months for us to obtain your old records from your old doctor's surgery.

E Mail Reliability & Confidentiality

Please understand this form will be transmitted by E Mail. E Mail is never guaranteed to be reliable and totally confidential- it will pass through our ISP's computers, for instance.

If you prefer not to use E Mail, please simply come to the hatch and collect a form

Tip

If you choose to complete this form, one per family member registering, you may well save yourself time by ensuring your "Autocomplete Forms" is turned on

First, some basic information we need to register you with the Practice.

Family Name (Necessary)

Previous Family Names (maiden name, etc)

First Name(s)   (Necessary)

Date of Birth   (Necessary)

Town & Country of Birth   (Necessary)

Sex     Male Female    (Necessary)

NHS Number (if available, please- on your Medical Card)

Title (Necessary)

House name

House street number

Street or Road    (Necessary)

Town or Village (Necessary)

Post Code (Necessary)

Home Phone number

Work Phone Number

Mobile Phone Number

E Mail Address

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

(If you are registering a New born child, please just insert "new Baby" in these two boxes)

Your last address in the UK, with town, county and postcode

(Necessary)

Name & address of your last doctor in the UK

(Necessary)

If you are returning from Abroad or were in the Armed Services, we need the following information- if this DOESN'T APPLY to you, please click here to go on and omit

If you are from abroad

Your first UK address where registered with a GP

Name & Address of previous doctor while at that address

If previously resident in UK, date of leaving

If you are returning from the Armed Services

Address before enlisting

Service or Personnel Number

Enlistment Date

Dispensing

Do you live over 1 mile from a chemists shop as the crow flies? Yes No (Necessary)

Past Medical History

Please list:-

all serious illnesses

conditions for which you receive regular or intermittent treatment

operations you have had

please put approximate year first, and put a new line after each illness or operation

eg. 1975 appendix removed eg. 1990 high blood pressure eg. 2000 diabetes

Medicines you take & Allergies

Please list any pills, drugs (legal or illegal) or treatments you take which you get from a doctor, drug dealer, chemist or herbalist. If you are on repeat medication from your old doctor, we'd value your old repeat slip from your old surgery.

for each drug, please put the strength (dose), how often per day, and the amount used per month

eg. aspirin - 75mg tabs - two each morning - 56 a month eg. Beconase nose spray - one puff, twice a day - 1 pack a month

Please list any allergies you have

Lifestyle

Have you ever smoked regularly?      Yes No

If you have never smoked regularly, click here to go on.

If so, amount per day

Year when you stopped, if applicable

Does anybody else in your house smoke? Yes No

If so, who?

How much alcohol do you drink in an average week?

How much exercise do you take in an average week?

What is your job? (If retired, what was your job?)

How tall are you?

How much do you weigh?

Family History

Can you tell us about your parents' health- if dead , what did they die of? Roughly how old were they?

Father      Mother

Brothers     Sisters

Has a close relative (parent, brother or sister) had angina or a heart attack before the age of 60yr?   Yes No

Immunisations

Can you tell us about any immunisations you can remember having?

eg for a child

1996 usual Diptheria, Pertussis (Whooping Cough) & Tetanus (DPT or Triple) Jabs - course of three & polio by mouth

eg. 1997 HIB jab & booster a year later eg. 2001 Diptheria Tetanus Booster, oral polio eg. 2002 typhoid and hepatitis A to go to India

Is there anything else you think we should know about you that would help us to help you?

Organ & Blood Donation

NHS Organ Donor Register

I would like to join the NHS Organ Donor Register as someone whose organs may be used for transplantation after my death.

Please fill boxes as appropriate    (necessary to check at least one)

Kidneys       Heart         Liver         Corneas

Lungs          Pancreas          Any part of my body

I do not wish to donate any part of my body

NHS Blood Donor Registration

I would like to join the NHS Blood Donor Register as someone who may be contacted and may be prepared to donate blood        Yes No (necessary)

Tick here if you've given blood in the last 3 years

Thanks for taking the time to complete this form- the details you have supplied will help make your care more efficient.

We hope you'll take the opportunity to make an appointment with sister for a new patient medical. She'll run through this medical history with you, check your blood pressure and urine for sugar, and discuss if you have any problems we might be able to help you with.

Before proceeding, may we remind you once more of the Confidentiality Problems that E Mail poses. If you have concerns, you could print out this page now on your printer, and let us have a copy. But if you are happy to submit your details by E mail, please click on the button below to submit your form.