Title
*
Mr
Mrs
Ms
Mx
Miss
Master
Dr
Name
*
First Name
Last Name
Previous Surnames
Date of Birth
*
MM
DD
YYYY
Gender
*
Male
Female
Indeterminate
Town and Country of Birth
*
Home Address
*
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Secondary phone number
Can we contact you by text?
*
Can we contact you by email?
*
Please specify the ethnic group you consider you belong to:
*
I do not wish to state
White British
White Irish
Black Caribbean
Black African
Black Caribbean and White
Black African and White
Indian
Pakistani
Bangladeshi
Other ethnic group
Do you speak English?
*
Do you read English?
*
First Language:
Previous address in UK:
Please include postcode. This field is compulsory if you have a previous address in the UK.
Name and address of previous GP:
Date you came to live in the UK
This field is compulsory is you are registering with the NHS for the first time.
MM
DD
YYYY
Date you left the UK
MM
DD
YYYY
Date you returned to the UK
This field is compulsory is you are returning from abroad.
MM
DD
YYYY
Please select one of the following statements:
ONLY IF YOU ARE NOT ORDINARILY A RESIDENT IN THE UK
Height
*
Weight
*
Smoking status
*
If smoker/ex smoker, how many cigarettes per day?
How often do you have a drink containing alcohol?
*
How many units of alcohol do you drink on a typical day when you are drinking?
*
One alcohol unit equals to half pint of a regular beer, half a small glass of wine or one single measure of spirits
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?
*
Do you have any allergies?
If so, please specify what you are allergic to, what happens and when you had your first reaction
Please list any immunisations/vaccinations you have had:
Please include dates
When was your last cervical smear?
MM
DD
YYYY
Was it done at
What was the result of the cervical smear?
Do you still have your ovaries?
Having read the above information regarding your choices, please choose one of the options below:
I declare that the information I give on this form is correct and complete. I understand that if it is not correct, appropriate action may be taken against me.
*
Signature
*
Print name
*
Relationship to patient
I certify that the information I have provided is correct and consent to my personal and medical information being used as stated above
*
Thank you! We will send you a text message to confirm your registration.
ORGAN DONATION - CHANGE IN LAW
What is changing? From 20 May 2020, all adults in England will be considered to have agreed to be an organ and tissue donor when they die unless they recorded a decision not to donate or are in one of the excluded groups. This is commonly referred to as an ‘opt out’ system. This means that if you have not confirmed whether you want to be an organ donor – either by recording a decision on the NHS Organ Donor Register or by speaking to friends or family – it will be considered that you agree to donate your organs when you die.
For further information please visit www.organdonation.nhs.uk or telephone 0300 303 2094
NHS Blood Donor registration
If 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 03001232323
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.
