New Patient Information Record

Your Details

Full Name *

Date of Birth *

Sex *

Male

Female

Address (including post code) *

Home Tel *

Mobile Tel

Work/Daytime Tel

Email Address

Marital Status *

Please state your occupation

Contact Details (cont.)

Please note that your mobile number, with the exception of out of hours service, will not be shared with any other organisations without your consent.

Do you consent to the practice contacting you via email? *

Yes

I do not have an email address

Do you consent to the practice contacting you via text? (This will include appointment reminders, some test results, and advice about your health) *

Yes

I do not have a mobile number

Next of Kin Details

Name of your dedicated Next of Kin. *

Relationship with your NOK. *

Contact Number of your NOK. *

Carer Status

Are you a carer? *

Yes No

Do you have a carer? *

Yes No

If you do have a carer, please type their name and contact number.

Ethnic Category

Medication

If you take regular medication, please bring in a copy of your repeat prescription from your previous surgery at your earliest convenience. This will ensure you get the correct medication and dosage. *

I do take regular medication. I acknowledge the above statement and will action at the earliest convenience.

I do not take regular medication.

Height/Weight Recordings

Please input your current height

Please input your current weight

Please input your current blood pressure reading (if known)

Smoking Status

Please select your Smoking Status *

Current Smoker

Ex-Smoker

Never Smoked

If you are a Current Smoker, please put the amount per day you smoke. For Quitters Advice please call 0845 602 4663.

Alcohol Status

Please tick the applicable box (+score)

Medical Conditions

Female Patients

Have you had a cervical smear within the last 3-5 years?

Yes No

If so, please state when, where, and the result of your smear.

Online Services: Appointment Booking, Prescriptions and Medical Records

Once we receive your registration forms and ID checks have been completed, you will be sent your login details if you wish to have access to the following services below.

Do you wish to have online access to booking appointments? *

Yes No

Do you wish to have online access to request repeat medications? *

Yes No

Do you wish to have online access to your medical records? *

Yes No

Summary Care Record Disclaimer

Summary Care Record (SCR). The idea of the SCR is that basic health information about you personally is available electronically across health settings. So if you found yourself unconscious in an A&E department, for example, the doctors there would be able to see any medication, allergies or medical conditions which might be crucial to them looking after you. Only authorised staff who are directly involved in caring for you can see it. All patients will be automatically opted in to share medication, allergies, and adverse reactions. For more information about your SCR and how to share additional information visit. www.digital.nhs.uk/summary-care-record or see our website under ‘Practice Policies’. *

I acknowledge the information provided. I wish to stay in.

I acknowledge the information provided. I wish to opt out.

If you wish to OPT OUT of sharing your summary care record, please sign with your name below (please do not sign if you wish to STAY IN).

The information you provide on this form will be sent to our practice and used only to deal with your request. Depending on the form, this may include your contact details, personal information and health information. The practice may add it to your medical record and, where needed for your care, share it with other NHS and care services. To find out how we protect and use your information, please read our privacy policy on our website.

I confirm the information I’ve given is correct and I understand how it will be used

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New Patient Information Record

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