Who is being registered? (Required)
Please choose the correct age band so we can show you the correct questions below.
Patient's details Title (Required) Date of birth (Required) Sex (Required) Email address (Required) Please help us trace your previous medical records by providing the following information Your previous address in UK (Required)
Please enter N/A if not applicable
Are you retired? (Required) Are you homeless? (Required) If you are homeless, may we use the address you registered with for confidential post? (Required) Do you have a social worker? (Required) If yes, please provide the name and contact details (Required) Further information Adult email (Required)
This is the Adult's email address. If the child is over 13 please provide the email address for the responsible adult here and the child's email in the box below (it is only visible if the correct age is selected above).
Child's email (Required) Next of Kin Do they have any formal power of attorney for medical care? (if so, please attach the certificates below) (Required)
Note, we will only contact this person in case of emergencies, and we will never share confidential information without your consent
More about a child or newborn Their current home address (Required) Name and address of school/nursery attended (Required) Communication needs Do you require an interpreter?
We offer double appointments for patients who need a language interpreter or BSL. Please ask at reception when booking an appointment.
Do you have any specific communication needs? By leaving this section blank we will not record the need for alternative communication methods in your record. Do you have a learning disability? (Required) Please provide further information Your lifestyle How often do you physically exercise? (Required) Smoking Are you a smoker? (Required)
If yes – we offer smoking cessation services at the practice. Please tick if you would like more information about this.
Please send me smoking cessation services information (Required) Do you use an e-cigarette? (Required) How often do you have a drink containing alcohol? (Required) How many units of alcohol do you drink on a typical day when you are drinking? (Required) 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? (Required) Alcohol consumption
Part Two Scores of 5 or more in Part 1 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? 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? Medical information Do you currently have or had any of the following? (Required) Any other conditions, operations or hospital admission details: Please list any immunisations or vaccinations you have had Do you have any allergies? (Required)
Includes food, drug and environmental allergies
Allergy details (Required) Are you currently receiving care elsewhere? (Required)
Please let us know if you are currently under the care of a Hospital or Consultant outside our area.
Please provide further information (Required) Please list below your current repeat medication (Required)
Please enter N/A if not taking any repeat medication
Family history Are you adopted? (Required) Does anyone in your family have or previously had any of the following (Required) Please give any details if you have ticked any of the above Females only Please let us know the date of your last cervical screening (smear) test
(if you are over 25 years old)
Have you had any children? (Required) Please give the dates of birth of your children (Required) Have you had a hysterectomy? (Required) Do you have a coil or implant? (Required) Looked after child/Child in care
A child who has been in the care of their local authority for more than 24 hours is known as a looked after child/child in care.
Are you a looked after child? (Required) Who are you living with? (Required) If yes, please provide the name and contact details (Required) Disability
You're disabled under the Equality Act 2010 if you have a physical or mental impairment that has a 'substantial' and 'long-term' negative effect on your ability to do normal daily activities.
Do you have a disability? (Required) Do you need information communicated to you in a specific format? (Required) Do you need support when attending the surgery? (Required) If yes, please describe any special help you require: (e.g. unable to manage stairs, easy-read information, sight/hearing assistance) Organ donation
In England it is considered that you agree to become an organ donor when you die if:
you are over 18; you have not opted out; you are not in an excluded group.
Find out more on
www.organdonation.nhs.uk or call 0300 123 23 23 to register your decision. Patient Participation Group
Our Patient Participation Group (PPG) is chaired by patients and provides the practice with feedback on how we improve our service delivery to meet the needs of our patients. We are an enthusiastic group and are always looking for new members to contribute.
Please tick here if you would like to be added to our PPG mailing list, to receive news and invitations to PPG meetings New borns and under 5 immunisations For new-born babies and children aged under 5 years, we require an up-to-date immunisation history. If you do not have this information please tick here (Required) Students only
Students are at risk of certain infections including mumps, meningitis and sexually transmitted infections, as well as
mental health issues including stress, anxiety and depression. Please see www.nhs.uk/Livewell/Studenthealth
I am less than 24 years old and have had two doses of the MMR Vaccination I am less than 25 years old and have had a Meningitis C Vaccination Surgery communication consent Would you like to register for online services? (Required)
You can book/cancel appointments, order prescriptions and see your read coded record and results online
Do you consent to receiving SMS messages? (Required)
These will be text messages relating to your care e.g. appointment reminders and when we need you to contact the surgery?
Can we contact you by email? (Required) Signature
You may be asked to sign this form when you visit the practice and provide ID and proof of address.
If you were born outside of the UK, you may be required to bring your Passport and Visa with you.
Today's date (Required) Not for urgent medical help (Required) Consent (Required)