Adult New Patient Registration Form

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All questions marked with a * are mandatory

Patient's Details
Title: *
  
Gender: *
Do you identify differently?:
Do you have a nominated pharmacy for electronic prescribing?:
Nominate a pharmacy means we can send any prescriptions directly to the pharmacy without you needing to come to the surgery
include the full address and post code of your chosen pharmacy
Are you happy for us to contact you by email?: *
Are you happy for us to contact you by text message? : *
 
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NHS

Your NHS Number

Help us to help you

You do not need to know your NHS number to use NHS services. However, providing this reduces the time it takes to process your registration. It helps us get you registered quicker.

  How to find your NHS Number

Help us to help you.

 

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Ethnicity & Religion
Do you speak English?:
Do you read English?:
Will you require an interpreter when you see the doctor/nurse?:
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Emergency Contact
Are they your Next of Kin?:
Do you give us permission to discuss your medical records with them?:
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Previous Details
Are you registering for the first time in the UK? : *
Have you recently moved to the UK: *
Please include postcode
Are you returning from abroad?: *
If you are from abroad
Please use this date format: DD/MM/YYYY
Refugee: *
Asylum Seeker: *
Are you returning from abroad? : *
If you are returning from abroad

This assumes that you have previously been registered with the NHS in the UK

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Were you ever registered with an Armed Forces GP
Were you ever registered with an Armed Forces GP: *

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

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:
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Supplementary Questions - If you are not a resident in the UK, but visiting or moving to the UK
New Patient Registration

Anybody in England can register with a GP practice and receive free medical care from that practice.

However, if you are not ‘ordinarily resident’ in the UK you may have to pay for NHS treatment outside of the GP practice.

  • Being ordinarily resident broadly means living lawfully in the UK on a properly settled basis for the time being. In most cases, nationals of countries outside the European Economic Area must also have the status of ‘indefinite leave to remain’ in the UK.
  • Some services, such as diagnostic tests of suspected infectious diseases and any treatment of those diseases are free of charge to all people, while some groups who are not ordinarily resident here are exempt from all treatment charges.
  • More information on ordinary residence, exemptions and paying for NHS services can be found in the Visitor and Migrant patient leaflet, available at reception. Alternatively for more information go to the NHS Website

You may be asked to provide proof of entitlement in order to receive free NHS treatment outside of the GP practice, otherwise you may be charged for your treatment. Even if you have to pay for a service, you will always be provided with any immediately necessary or urgent treatment, regardless of advance payment.

The information you give on this form will be used to assist in identifying your chargeable status, and may be shared, including with NHS secondary care organisations (e.g. hospitals) and NHS Digital, for the purposes of validation, invoicing and cost recovery. You may be contacted on behalf of the NHS to confirm any details you have provided.

Please select one of the following statements:: *
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European Economic Area (EEA) Country
Do you live in another EEA country, or have moved to the UK to study or retire, or live in the UK but work in another EEA member state?:
Do you have a non-UK European Health Insurance Card (EHIC) or a Provisional Replacement Certificate (PRC) ?:

Please Note

If you are visiting from another EEA country and do not hold a current EHIC (or Provisional Replacement Certificate (PRC))/S1, you may be billed for the cost of any treatment received outside of the GP practice, including at a hospital.

Please enter the details from your EHIC or PRC below.

S1 Form

Please upload a copy of your S1 form

  • You can upload a document, photo or scan
Only following file extensions are allowed: jpg, jpeg, png, webp, pdf, doc, docx, pptx

How will your data be used?

  • By using your EHIC or PRC for NHS treatment costs your EHIC or PRC data and GP appointment data will be shared with NHS secondary care (hospitals) and NHS Digital solely for the purposes of cost recovery.
  • Your clinical data will not be shared in the cost recovery process.
  • This form collects personal and medical information about you and we use this information to allow the practice team to contact you.
  • Your EHIC, PRC or S1 information will be shared with The Department for Work and Pensions for the purpose of recovering your NHS costs from your home country.
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Carers

A carer is anyone, including children and adults who looks after a family member, partner, or friend who needs help because of their illness, frailty, disability, a mental health problem or an addiction and cannot cope without their support.

  • This is different from normal parenting duties for a child
Do you have a carer?: *
UK number only
If a company of organisation, please indicate which above.
Do you give us permission to discuss your medical record with your carer?: *
Are you a carer for someone?: *
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Allergies
Do you have any allergies?: *
Add a medication:
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Lifestyle

Your Height

What unit of measurement are you using?: *
Conversion from Feet & Inches to Centimetres

Your Weight

What unit of measurement are you using?: *
Conversion from Stones & Pounds to Kilograms
Your Blood Pressure
Your Smoking Status
Please choose from one of the following options: *
Stop Smoking

Steps to quit smoking

Stopping smoking lets you breathe more easily. People breathe more easily and cough less when they give up smoking because their lung capacity improves by up to 10% within 9 months.

  NHS Stop Smoking Services

  Take steps now to stop smoking

  10 self-help tips to stop smoking

Are you interested in further advice and support on how to quit?: *
Adult Females
Are you currently, or think you may be pregnant?:
Do you have any children?:
Have you had a cervical smear? :
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Your Personal Alcohol Consumption

What does 1 unit of alcohol look like?

Each of the examples depicts 1 unit of alcohol based on the Alcohol by Volume (ABV) against the Volume (ml) displayed.

Click here for NHS guidance about calculating alcohol units

  • Cider

    Cider 218ml

    Standard 4.5% ABV

  • Wine

    Wine 76ml

    Standard 13% ABV

  • Whisky

    Whisky 25ml

    Standard 40% ABV

  • Beer

    Beer 250ml

    Standard 4% ABV

  • Alcopop

    Alcopop 250ml

    Standard 4% ABV

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 were drinking in the past year?: *
How often did you have six or more drinks on one occasion in the past year?: *
Your Personal Alcohol Consumption - Part 2
How often during the last year have you found that you were not able to stop drinking once you had started?: *
How often during the last year have you failed to do what was normally expected from you because of your drinking?: *
How often during the last year have you needed an alcoholic drink in the morning to get yourself going after a heavy drinking session?: *
How often during the last year have you had a feeling of guilt or remorse after drinking?: *
How often during the last year have you been unable to remember what happened the night before because you had been drinking?: *
Have you or somebody else been injured as a result of your drinking?: *
Has a relative or friend, doctor or other health worker been concerned about your drinking or suggested that you cut down?: *
 
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Audit Score Result 0 - 7 (Lower Risk)

Lower Risk 

, you have a score of 

Your answers suggest you are at a lower risk of being dependent on alcohol.

  • If you are drinking less than 14 units of alcohol per week, then your drinking is within the UK Chief Medical Officers' low risk drinking guidelines.

Caution advised

If you are drinking regularly at or above the low risk guidelines of 14 units a week, or, you are drinking six or more units if you are female or eight or more units  if you are male in one single session (binge drinking), please consider the increased serious risks to your health being caused by your current drinking pattern.

Audit Score Result 8 - 15 (Increasing Risk)

Increasing Risk

, you have a score of 

Your answers suggest you are at an increasing risk of being dependent on alcohol.

Caution

  • Your drinking is dangerous to your health, increasing your risk of serious health problems including seven types of cancer, liver and heart disease, and high blood pressure.
  • Unless you cut down you are at risk of damaging your health.
Audit Score Result 16 - 19 (Higher Risk)

Higher Risk

, you have a score of 

Your answers suggest you are at Higher Risk of being dependent on alcohol.

Your drinking is dangerous to your health.

  • You are drinking far more than the UK Chief Medical Officers' low risk drinking guidelines of 14 units a week.
  • Regularly drinking this much causes a range of serious health harms including seven types of cancer, liver disease and high blood pressure.
Audit Score Result 20+ (Possible Dependence)

Possible Depandance

, you have a score of 

Your answers suggest you are at High Risk of being dependent on alcohol.

  • Your drinking is dangerous to your health.
  • You are drinking far more than the UK Chief Medical Officers' low risk drinking guidelines of 14 units a week.
  • Regularly drinking this much causes a range of serious health harms including seven types of cancer, liver disease and high blood pressure.

Alcohol Support

If you have become dependant on alcohol, you will have found it difficult to fully control your drinking in some way. So you'll probably need some help either to cut down and control your drinking or stop completely, and also some plans to maintain the improvement after that.

  Find Alcohol Support Services in your area

  Tips on cutting down

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Immunisation History
Tetanus:
Typhoid:
Hepatitis A:
Polio:
Yellow Fever:
Hepatitis B:
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Medical History
Please include dates.
Please include dates.
Have any close relatives (father, mother, sister, brother only) ever suffered from any of the following:
Add another medication?:
How do you describe your sight?:
How do you describe your hearing?:

Over 75 years old?

  • The Department of Health has advised that all patients of 75 years and older have a named and accountable GP to oversee their care.
  • Please ask the name of the GP assigned to oversee your care.
  • Please note this does not prevent you from seeing the GP of your choice.
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Summary Care Record

Summary Care Record (SCR)

The Summary Care Record (SCR) system is designed to help both your GP and any emergency staff you contact when the surgery is closed to treat your health needs more efficiently.

  • Your information will be shared between your GP practice, our local hospital and Out Of Hours service.
  • This will enable your GP surgery to access results and any visits you have at the hospital quickly and efficiently, but it also means that if you have an emergency and contact the Out Of Hours service or visit A&E they will have access to your current medications as well as allergies and are better able to treat you.
SCR Options:

If you do not complete this section, a Summary Care Record will be created for you based on implied consent

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NHS Logo

Patient  Identification

Help us to help you

You do not need to provide proof of address or ID to use NHS services. However, providing this reduces the time it takes to process your registration. It helps us get you registered quicker.

Acceptable forms of Photo ID

  • Photo Driving License
  • Passport

ID documents are not stored and will be securely destroyed in line with our data retention schedule.

Acceptable forms of Proof of Residence

  • Tenancy agreement
  • Mortgage statement
  • Bank statement
  • Utility bill (date within the past 3 months) 

Please upload a copy of your ID and Proof of Address

  • You can upload a document, photo or scan
Only following file extensions are allowed: jpg, jpeg, png, webp, pdf, doc, docx, pptx
Only following file extensions are allowed: jpg, jpeg, png, webp, pdf, doc, docx, pptx
Only following file extensions are allowed: jpg, jpeg, png, webp, pdf, doc, docx, pptx
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Organ Donation

NHS Organ Donor registration

The law around organ donation in England changed to an opt-out system, to enable more people to save more lives.

This means that unless you choose to opt out, or are in an excluded group, you will be considered to have agreed to be an organ donor when you die.

The best way to make your decision known is to record it on the NHS Organ Donor Register and tell your loved ones.

  Find our more about Organ Donation

Yes I do donate

Across the rest of the UK

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Blood Donor

NHS Blood Donor registration

Giving blood saves lives.The blood you give is a lifeline in an emergency and for people who need long-term treatments.

This means that unless you choose to opt out, or are in an excluded group, you will be considered to have agreed to be an organ donor when you die.

The best way to give blood is to apply using the NHS Blood Donor Register

  Find our more about Blood Donation

Yes I do donate

We need

  • Nearly 400 new donors a day to meet demand
  • Around 135,000 new donors a year to replace those who can no longer donate
  • 40,000 more black donors to meet growing demand for better-matched blood
  • 30,000 new donors with priority blood types such as O negative every year
  • More young people to start giving blood so we can make sure we have enough blood in the future
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Data Sharing Consent Choices

As a default, we will set your record as available to share both in SystmOne and the Summary Care Record.

For further information on data sharing please visit our policies section

Do you consent to your GP Practice sharing your health record with other local organisations who care for you?: *
Do you consent to your GP Practice viewing your health record from other organisations that care for you?: *
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Application For Online Access To My Medical Record
I wish to have access to the following online services (please tick all that apply):
I wish to access my medical record online and understand and agree with each statement (tick):
I would like to receive my login details via:
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What happens to my information?

  • Personal and medical information about patients registered at this practice are primarily kept electronically, although some is kept in paper form. Some information will be sent to hospital consultants and other health professionals to whom you are referred by your GP in order to provide continued healthcare and obtain treatment for you.
  • We sometimes use accredited suppliers for our communication with you, for example when we send recall letters for review clinics or medication reviews. All suppliers we use are checked carefully to ensure they comply with strict confidentiality protocols.
  • To ensure the security of all patient information, all staff that has access to your records is covered by confidentiality clauses in their contracts and the Data Protection Act and the Freedom of Information Act. Our guiding principle is that we hold your records in strict confidence.
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Privacy Consent

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