New Patient Registration Adult Please complete the online form to register as a new patient. New Patient Registration Adult Step 1 of 2 50% Please Note: A supporting signed letter from the patient will be required either posted or emailed to the practice, to complete the registration.Background DetailsContact DetailsNHS Number Optional Title DrMissMrMrsMsProf.Rev. Prefix Name Previous Surname (if applicable) Optional GenderPlease SelectFemaleMaleDate of Birth Day Month Year Address Street Address Address Line 2 City Post code Previous Address Street Address Optional Address Line 2 Optional City Optional Post Code Optional Home Telephone OptionalMobile NumberDo you content to be contacted via SMS?Please SelectYesNoEmail Enter Email Confirm Email Do you consent to be contacted Via email?Please SelectYesNoNext of KinDo you have a next of kin?Please selectYesNo(emergency contact person)Name PhoneRelationship to you Previous GPGP Name Address Street Address Address Line 2 City Post Code Other DetailsCountry of Birth EthnicityPlease SelectWhite (UK)White (Irish)White (Other)Black CaribbeanBlack AfricanBlack OtherBangladeshiIndianPakistaniChineseOtherReligon OptionalPlease SelectC of ECatholicOther ChristianBuddhistHinduMuslimSikhJewishJehovah's WitnessNo ReligionOtherHousing Status OptionalPlease SelectOwn HouseRented HouseShared HouseNursing HomeResidential HomeSheltered HomeHomelessHouseboundAsylum SeekerRefugeeEmployment Status OptionalPlease SelectEmployedSelf-employedStudentUnemployedHouse HusbandHouse WifeCarerRetiredAre you an overseas visitorPlease SelectYesNoIf you hold a European Health Insurance Card Please contact us with details of this.Are you a Military VeteranPlease SelectYesNoCommunication NeedsWhat is your main spoken language? Do you need an interpretor?Please SelectYesNoDo you have any communication needs? If yes: What?Do you have a learning disability?Please selectYesNoIf Yes please request a Learning Disability Screening Tool formCarer DetailsDo you have a Carer?Please selectYesNoAre you a Carer?Please SelectYes – Informal / UnpaidYes – Occupational / PaidNoIf you are being supported by Social Services or Children’s Services, please tell us here: OptionalMedical HistoryHave you suffered from any of the following conditions?Please SelectAsthmaCOPDEpilepsyHeart DiseaseHeart FailureHigh Blood PressureDiabetesKidney DiseaseStrokeDepressionUnderactive ThyroidCancerNoneType of Cancer: Any other conditions, operations or hospital admission details: Optional If you are currently under the care of a Hospital or Consultant outside our area, please tell us here: Optional Family HistoryPlease record any significant family history of close relatives with medical problems and confirm which relative e.g. mother, father, brother, sister, grandparent.Relative Optional i.e Parent, Sibling, Grandparent, Aunt/Uncle/Cousin etcMedical Problem Optional AllergiesPlease record any allergies or sensitivities MedicationPlease check and include as much information about your current medication below.Please give us your previous repeat medication list if possible, a medication review appointment may be needed: Optional Your LifestyleAlcoholPlease answer the following questions which are validated as screening tools for alcohol use: AUDIT–C QUESTIONS Please check the correct boxes and check your score. (Scores can be found to the right of your answer)How often do you have a drink containing Alcohol?Please SelectNever (0)Monthly or Less (1)2-4 times per month (2)2-3 times per week (3)4+ times per week (4)How many units of alcohol do you drink on a typical day when you are drinking?Please Select1-2 (0)3-4 (1)5-6 (2)7-9 (3)10+ (4)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?Please selectNever (0)Less than monthly (1)Monthly (2)Weekly (3)Daily or almost daily (4) A score of less than 5 indicates lower risk drinking Scores of 5 or more require the following 7 questions to be completed:Total Score: 4 or less 5 or more A score of less than 5 indicates lower risk drinking, Scores of 5 or more requires the following 7 questions to be completed: How often during the last year have you found that you were not able to stop drinking once you had started?Please SelectNever (0)Less than monthly (1)Monthly (2)Weekly (3)Daily or almost daily (4)How often during the last year have you failed to do what was normally expected from you because of your drinking?Please SelectNever (0)Less than monthly (1)Monthly (2)Weekly (3)Daily or almost daily (4)How often during the last year have you needed an alcoholic drink in the morning to get yourself going after a heavy drinking session?Please SelectNever (0)Less than monthly (1)Monthly (2)Weekly (3)Daily or almost daily (4)How often during the last year have you had a feeling of guilt or remorse after drinking?Please SelectNever (0)Less than monthly (1)Monthly (2)Weekly (3)Daily or almost daily (4)How often during the last year have you been unable to remember what happened the night before because you had been drinking?Please SelectNever (0)Less than monthly (1)Monthly (2)Weekly (3)Daily or almost daily (4)Have you or somebody else been injured as a result of your drinking?Please SelectNo (0)Yes, but not in the last yearYes, during last yearHas a relative or friend, doctor or other health worker been concerned about your drinking or suggested that you cut down?Please SelectNo (0)Yes, but not in the last yearYes, during last yearTotal Score? From the previous 7 questions.SmokingDo you smoke?Please SelectNever Smokedex SmokerYesE-CigaretteHow many cigarettes did/do you smoke a day? Would you like help to quit smoking? For further information, please see:www.nhs.uk/smokefreeHeight and WeightHeight Weight Women's HealthAre you Female?Please SelectYesNoDo you use any contraception?Please SelectYesNo (If needed book an appointment)Are you currently pregnant or think you may be?Please SelectYesNoExpected due date Day Month Year StudentsStudents are at risk of certain infections including mumps, meningitis and sexually transmitted infections, as well as mental health issues including stress, anxiety and depression. For further information, please see: www.nhs.uk/Livewell/Studenthealth Are you a student?Please selectYesNoI am less than 24 years old and have had two doses of the MMR VaccinationPlease SelectYesNoUnsureI am less than 25 years old and have had a Meningitis C VaccinationPlease SelectYesNoUnsureElectronic PrescribingIf you would like your prescriptions to be sent electronically, please provide details of the pharmacy you would like to use: Optional PPG – Patient Participation GroupWould you like to be involved in our Patient Participation Group?Please selectYesNoBlood and Organ DonationBlood Donation I am already a blood donor I wish to be a blood donor I do not wish to be a blood donor Organ Donation I am already registered as a donor I wish to be a donor – all body part I wish to be a donor – for these body parts: I do not wish to be a donor Which organs would you like to donate: OptionalYou can register Online -OR- You can call(030 0123 2323) and speak to an advisor who will send out a donor card. ConsentI confirm that the information I have provided is true to the best of my knowledge.Name Date Day Month Year Your Health RecordDo you consent to your GP Practice sharing your health record with other organisations who care for you? I wish to give EXPRESS CONSENT for medication, allergies and adverse reactions only to be included in my Summary Care Record I wish to give EXPRESS CONSENT for medication, allergies, adverse reaction and additional information to be included in the my Summary Care Record I DO NOT CONSENT to have my Summary Care Record and do not wish to have one Do you consent to your GP Practice viewing your health record from other organisations that care for you? Yes (recommended option) No Your Summary Care Record (SCR)Do you consent to having an Enhanced Summary Care Record with Additional Information? Yes (recommended option) Optional No Optional I wish to have online access to: Please tick all that apply View & book appointments View & request medication Access my coded medical record (contains any medical codes that have been recorded) Access my full medical record (contains medical codes and any free text that has been recorded) Access my Summary Care Record Complete online questionnaires I wish to access my medical record and understand and agree with each statement: Please tick all that apply I have read and understood the ‘Important Information’ section below I will be responsible for the security of the information that I see or download If I choose to share my information with anyone else, this is at my own risk I will contact the practice as soon as possible if I suspect that my account has been accessed by someone without my agreement If I see information in my record that it not about me, or is inaccurate I will log out immediately and contact the practice as soon as possible Access to GP Online Services Important Information – Please read before completing form below If you wish to, you can now use the internet (via computer or mobile app) to book appointments with a GP, request repeat prescriptions for any medications you take regularly and look at your medical record online. You can also still use the telephone or call in to the surgery for any of these services as well. It’s your choice. It will be your responsibility to keep your login details and password safe and secure. If you know or suspect that your record has been accessed by someone that you have not agreed should see it, then you should change your password immediately. If you are unable to do this for some reason, we recommend that you contact the practice so that they can remove online access until you are able to reset your password. If you print out any information from your record, it is also your responsibility to keep this secure. If you are at all worried about keeping printed copies safe, we recommend that you do not make copies at all. During the working day it is sometimes necessary for practice staff to input into your record, for example, to attach a document that has been received, or update your information. Therefore you will notice admin/reception staff names alongside some of your medical information – this is quite normal. The definition of a full medical record is all the information that is held in a patient’s record; this includes letters, documents, and any free text which has been added by practice staff, usually the GP. The coded record is all the information that is in the record in coded form, such as diagnoses, signs and symptoms (such as coughing, headache etc.) but excludes letters, documents and free text. Before you apply for online access to your record, there are some other things to consider. Although the chances of any of these things happening are very small, you will be asked that you have read and understood the following before you are given login details. Forgotten history There may be something you have forgotten about in your record that you might find upsetting. Abnormal results or bad news If your GP has given you access to test results or letters, you may see something that you find upsetting to you. This may occur before you have spoken to your doctor or while the surgery is closed and you cannot contact them. Choosing to share your information with someone It’s up to you whether or not you share your information with others – perhaps family members or carers. It’s your choice, but also your responsibility to keep the information safe and secure. Coercion If you think you may be pressured into revealing details from your patient record to someone else against your will, it is best that you do not register for access at this time. Misunderstood information Your medical record is designed to be used by clinical professionals to ensure that you receive the best possible care. Some of the information within your medical record may be highly technical, written by specialists and not easily understood. If you require further clarification, please contact the surgery for a clearer explanation. Information about someone else If you spot something in the record that is not about you or notice any other errors, please log out of the system immediately and contact the practice as soon as possible. For further information, please see: www.nhs.uk/NHSEngland/AboutNHSservices/doctors/Pages/gp-online-services.aspx Date Optional MM slash DD slash YYYY Please upload a photo of your ID / Address Optional Drop files here or Select files Max. file size: 50 MB.