Registration Form If you are new to the area and wish to register with the Practice please complete the form below – each person registering will need to complete a form. Background DetailsName Dr.MissMr.Mrs.Ms.Mx.Prof.Rev. Title First Last Do you have a previous surname? Yes No Do you know your NHS number? Yes No Previous SurnameNHS NumberDate of Birth Day Month Year Gender Female Male 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 discloseFirst Spoken LanguageTown and Country of BirthAddress Street Address Address Line 2 City Postcode Contact NumberEmail Enter Email Confirm Email Do you have a previous GP in the UK? Yes No Please help us trace your previous medical records by providing the following information:Your previous address in the UK Street Address Address Line 2 City Postcode Name of doctor while at that addressAddress of previous doctor Street Address Address Line 2 City Postcode Are you from abroad? Yes No If you are from abroadYour first UK address where registered with a GP Street Address Address Line 2 City County / State / Region Postcode AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country If previously resident in UK, date of leaving Day Month Year Date you first came to live in the UK Day Month Year Other DetailsAre you ordinarily a resident in the UK? Yes No European Economic Area (EEA) CountryFor a list of EEA countries visit: www.gov.uk/eu-eeaDo 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? Yes No Nominated PharmacyNominated Pharmacy NameNominated Pharmacy Address Street Address Address Line 2 City Postcode LifestyleMarital Status Single, never married Married Civil Partnership Divorced Widowed Separated Which of the following options best describes you? Heterosexual or Straight Gay or Lesbian Bisexual Prefer not to say In another way Sex and gender identity – Which one of the following best describes how you think of yourself? Male (including trans men) Female (including trans women) Non-binary Prefer not to say In another way Is your gender identity the same as the gender you were given at birth? Yes No Prefer not to say Please specify the ethnic group you consider you belong to English Welsh Scottish Northern Irish British Irish Gypsy or Irish Traveller Any other White background White and Black Caribbean White and Black African White and Asian Any other Mixed / Multiple ethnic background Indian Pakistani Bangladeshi Chinese Any other Asian background African Caribbean Any other Black / African / Caribbean background Arab Any other ethnic group Prefer not to say What is your main religion? No religion Christian (including Church of England, Catholic, Protestant, and all other Christian denominations) Buddhist Hindu Jewish Muslim Sikh Other religion CommunicationDo you speak English? Yes No Do you read English? Yes No Are you a British Sign Language user? Yes No What is your main spoken language?DisabilitiesDo you have an impairment, health condition or learning difference that has a substantial or long term (over a year) impact on your ability to carry out day to day activities? (Tick all that apply) No known impairment, health condition or learning difference A long standing illness/health condition such as cancer, HIV, diabetes, chronic heart disease, asthma, or epilepsy A mental health impairment, such as depression, schizophrenia or anxiety disorder A physical impairment or mobility issues, such as difficulty using your arms or using a wheelchair or crutches A learning difficulty Neuro-diverse e.g. dyslexic, dyspraxic or AD(H)D Deaf or hearing impaired Blind or have a visual impairment uncorrected by glasses An impairment, health condition or learning difference that is not listed above Prefer not to say Do you have any specific information or communication needs which require reasonable adjustments? If so, please specify how we can meet these for you (e.g. large print, Braille, easy read communications)Armed ForcesHave you served in the UK Armed Forces and/or been registered with a Ministry of Defence GP in the UK or overseas? Yes No Do you have access to secure housing? Yes No What is your current immigration status? Asylum Seeker Failed Asylum Seeker None of the above Carer StatusDo 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 Emergency ContactFull NameRelationship to youContact NumberAre they your next of kin? Yes No Do you give us permission to discuss your medical records with them? Yes No Further DetailsHeightWeightSmoking Status Current Smoker Ex Smoker Never Smoked What do you smoke?e.g. Cigarettes, Vape, CigarsHow many do you smoke per day?Are you interested in advice on how to quit? Yes No Please state how much exercise and what type of exercise you do per weekAlcohol ScreeningThis 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 Monthly Weekly Daily or almost daily Do you have any significant family history we should be aware of?Medical HistoryIf none, please state ‘NA’.Major IllnessesPlease include datesPast OperationsPlease include datesFamily History IllnessesPlease include datesCurrent MedicationWe routinely offer HIV screening would you be interested in being screened? Yes No Sight Good Poor Registered Blind Hearing Good Poor Partially Deaf Deaf Are you 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.AllergiesDo you have any allergies? Yes No Please specify what you are allergic to, what happens and when you had your first reactionImmunisation HistoryIf none, please state ‘NA’.Please list any immunisations/vaccinations you have hadPlease include datesConsentFor anyone aged 16 and over, 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. Prescriptions are sent electronically to your nominated pharmacy. We will automatically nominate the pharmacy closest to your post code as part of your registration. If you prefer to use a different chemist please contact the practice to sign up for the Electronic Prescribing ServiceSummary 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 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 03001232323What 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.SignatureDeclaration I certify that the information I have provided is correct and consent to my personal and medical information being used as stated above. SignatureYour Full NameDate Day Month Year