New Patient Registration Form Personal DetailsTitle Mr Mrs Miss Ms Mx Dr Other NHS Number (if known) Optional First Names Surname Previous Surname Optional Date of Birth Day Month Year Gender Identity Male Female Other EthnicityPlease SelectWhite – BritishWhite – IrishWhite – TurkishWhite – GreekWhite – KurdishWhite – OtherAsian – IndianBritish IndianAsian – PakistaniBritish PakistaniAsian BangladeshiAsian – OtherBlack – CaribbeanBlack – AfricanBlack – OtherMixed – BritishMixed CaribbeanMixed – AfricanMixed – White & AsianMixed – OtherEthnic – ChineseEthnic – FilipinoEthnic – VietnameseEthic – OtherI do not wish to discloseReligion Optional Section BreakReligion OptionalSecond ChoiceThird ChoiceTown* and Country of Birth *Please include borough if born in LondonAddress Street Address Address Line 2 City Postcode Main Contact NumberMobile Telephone Number OptionalHome Contact Number OptionalWe will use your mobile number to send appointment reminders and health promotion details. I do not wish to receive these messages OptionalEmail Enter Email Confirm Email How would you prefer us to contact you? Letter Optional Email Optional SMS (text) Optional Phone Optional Please help us trace your previous medical records by providing the following information:Your previous address in the UK Street Address Optional Address Line 2 Optional City Optional Postcode Optional Name of doctor while at that address Optional Address of previous doctor Street Address Optional Address Line 2 Optional City Optional ZIP / Postal Code Optional If you are from abroadYour first UK address where registered with a GP Street Address Optional Address Line 2 Optional City Optional Postcode Optional If previously resident in UK, date of leaving Day Optional Month Optional Year Optional Date you first came to live in the UK Day Optional Month Optional Year Optional If this is your first GP registration in the UK, please provide us the name of the country and date of arrival.Country Name Optional Date of Arrival Optional Armed ForcesPlease 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: Regular Optional Reservist Optional Veteran Optional Family Member (Spouse, Civil Partner, Service Child) Optional DemographicsMarital Status Single, never married Married Civil Partnership Divorced Widowed Separated Other CarersDo you have caring responsibilities? None Primary carer of a child/children (under 18) Primary carer of disabled child/children Primary carer of disabled adult (18 and over) Primary carer of older person Secondary carer (another person carries out the main caring role) Prefer not to say Do you have a carer? Yes No Care agency and Contact details OptionalSecond ChoiceThird ChoiceCarer’s Name First Optional Last Optional Relationship to you Optional Address of carer Street Address Optional Address Line 2 Optional City Optional Postcode Optional Telephone number of carer OptionalNext of KinYour choice should be someone you feel close to. It does not have to be a blood relative or spouse. Before listing them on any medical documents, you should ask their permission and explain the role.Full Name Relationship to you Contact NumberCommunication and Access NeedsDo you speak English? Yes No Do you read English? Yes No Are you a British Sign Language user? Yes Optional No Optional What is your main spoken language? Do you need an interpreter? Yes No Do you have any specific mobility, information or communication needs? If so, please specify how we can meet these for you (e.g. large print, Braille, easy read communications) OptionalHearing aidBritish sign language (BSL)Makaton sign languageLarge printBrailleOtherHealth InformationHeight Optional (in centimetres)Weight Optional (in kilograms)Blood Pressure if known Optional How many of the below do you smoke per day?Smoking Current Ex Smoker Never Smoked Cigarettes per day Optional Nicotine filled electronic cigarette Yes Optional No Optional Other Optional How many devices a week Optional Are you interested in advice on how to quit? Yes Optional No Optional Alcohol ConsumptionThis is one unit of alcohol: Half pint of regular Beer/Lager/Cider 1 small glass of wine 1 single measure of spirits 1 single measure of aperitifs 1 small glass of sherry Each of these is more than one unit: Pint of regular Beer/Lager/Cider (2 Units) Pint of Premium Beer/Lager/Cider (3 Units) Alcopop or can/bottle of regular Lager (1.5 Units) Can of Premium Lager/Strong Beer (2 Units) Can of super strength lager (4 Units) Glass of wine (2 Units) Bottle of wine (9 Units) How often do you have a drink containing alcohol? Never Monthly or less 2-4 times per month 2-3 times per week 4+ times per week How many units of alcohol do you drink on a typical day when you are drinking? 1-2 3-4 5-6 7-9 10+ 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. Never Less than monthly Weekly Other What is the date and result of your last Smear test? (If applicable)Date Optional Result Optional Was this at: GP Surgery Optional Other NHS Optional Private Optional Abroad Optional Date of last Mammogram (if applicable): Optional Current MedicationPlease list any medications or treatments you are undertaking and for what condition. OptionalAllergiesDo you have any allergies? Yes Optional No Optional Please provide more information. OptionalPlease specify what you are allergic to, what happens and when you had your first reactionImmunisation HistoryPlease list any immunisations/vaccinations you have had OptionalPlease include datesOnline ServicesAnyone aged 11 and over can request access to online services. We offer online services for appointment booking and repeat prescription ordering. This is the quickest and easiest way to order your medication. Once registered, you will also be able to view your summary record, detailing current medication, allergies and vaccinations. You will soon receive an email from the practice with your log in details.These are confidential: It is your responsibility to ensure they can be received securely by email. I do not want to be registered for online services OptionalSummary Care RecordThis record will contain summary information about any medicines you are taking, allergies you suffer from and any bad reactions to medicines you have had to ensure those caring for you have enough information to treat you safely. Your Summary Care Record will be available to authorised healthcare staff providing you with care anywhere in England, but they will ask your permission before they look at it. This means that if you have an accident or become ill away from home, healthcare staff treating you will have immediate access to important information about your health.Do you consent to having a Summary Care Record? Yes No Medical Record Sharing allows your complete GP medical record to be made available to authorised healthcare professionals involved in your care. You will always be asked your permission before anybody looks at your shared medical record.Do you want to share your GP record? Yes No Your Medical Information – Sharing Your DataUnder the General Data Protection Regulations (GDPR), we have a responsibility to keep your medical records confidential. We need your consent to share this with other authorised health professionals involved in your care or in planning your care. You can find more information on the website at www.nhs.uk/your-nhs-data-matters. Please see the privacy notice on our website for more information on how your data is held and used by the practice. The NHS wants to make sure you and your family has the best care now and in the future. Your health and adult social care information supports your individual care. It also helps us to research, plan and improve health and care services in England. There are very strict rules on how this data can and cannot be used, and you have clear data rights. We are committed to keeping patient information safe and will always be clear on how it is used. You can choose whether or not your confidential patient information is used for research and planning. If you do not wish your information to be used in this way please opt-out by visiting NHS: Your Data Matters or by calling 0300 303 5678. The practice is unable to record this for you.NHS Organ Donor registrationFor more information on organ donation please visit: www.organdonation.nhs.ukNHS Blood Donor registrationIf you would like to join the NHS Blood Donor Register as someone who may be contacted and would be prepared to donate blood, please visit their website on: www.blood.co.uk or call direct on 03001232323SignatureDeclaration I certify that the information I have provided is correct and consent to my personal and medical information being used as stated above. Optional Signature Your Full NameDate Day Month Year