Thank you for completing this registration form. You are required to register in person at the surgery. Please be prepared to show ID if requested. Please remember to sign the final page.

PLEASE PRINT NAME CLEARLY

Title / Date of Birth
Gender / Town/Country of birth
Forename(s) / NHS number (if known)
Surname / Previous surname
Address
Postcode / Ethnicity: Please enter the ethnic group which you consider you belong to.
□ I do not wish to answer this question
Home telephone / Work telephone
(Under 16) Name of school
Mobile telephone / Can we contact you by text? YES/NO
Email address (PLEASE PRINT) / Can we contact you by email? YES/NO
Emergency contact:
Full name:
Relationship to patient:
Contact number:
Next of Kin? Yes □ No □
Emergency contact Yes □ No □ / Have you any allergies?
YES / NO (Please continue on a separate sheet if necessary)
Previous address in UK
Postcode / Name & address of previous doctor
If you are returning from abroad – (previously resident in UK)
Date of leaving:
Date of returning: / If you are from abroad – (registering for the first time in the UK)
Date you came to live in the UK:

Lifestyle

Weight (kg or st/lb) / Height (m or ft/in)
Do you smoke?
NO □ If you used to smoke, when did you stop?
YES □ Amount per day
How much exercise do you do per week?
How much, if any, alcohol do you drink per week?
PLEASE CIRCLE ONE ANSWER PER QUESTION
How often do you have a drink that contains alcohol? / Never / Monthly or less / 2-4 times per month / 2-3 times per week / 4 times per week
How many standard alcoholic drinks do you have on a typical day when you are drinking? / 1-2 / 3-4 / 5-6 / 7-8 / 10+
How often do you have 6 or more standard drinks on one occasion? / Never / Less than monthly / Monthly / Weekly / Daily or almost daily

Adult female patients only

Have you had a hysterectomy? If yes, give date & specify what type if you know. / YES/NO
Do you still have your ovaries? YES/NO
When was your last cervical smear? / Date:
Was it done:
□ By your previous GP
□ Family planning clinic / What was the result:
Suggested recall:

ALL PATIENTS

Immunisation History – (Please list any immunisations / vaccinations you have had including dates)

What happens to my information?

Personal and medical information about patients registered at this Practice are stored electronically and in paper form. Some of the information will be sent to hospital consultants and other health professionals to whom you are referred by your GP in order to provide continued health care and obtain treatment for you.

We sometimes use accredited suppliers for our communication with you, for example when we send recall letters for medication reviews or invitations to our flu clinics. 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 who have access to your details and medical records are covered by confidentially clauses in their employment contracts and the Data Protection Act and Freedom of Information Act. Our guiding principle is that we hold your records in strict confidence.

Summary Care Records

Summary Care Records (SCR) contain key information about medicines you are taking, allergies you suffer from and any bad reactions to medicines you have had in the past. Giving healthcare staff access to this information can prevent mistakes being made when caring for you in an emergency or when the surgery is closed. Your SCR will include your name, address, date of birth and your unique NHS number to help identify you correctly.

Our GP Practice is supporting Summary Care Records and as a patient you have a choice:

Yes, I would like a Summary Care Record. If you want a record you do not need to do anything further, one will be created for you when processing this registration form. If you have opted out of having a record in the past but have now changed your mind, let us know so one can be created for you.

No, I do not want a Summary Care Record.PLEASE COMPLETE THE ATTACHED OPT OUT FORM. If you do not want a record, you will need to fill in a Summary Care Record opt out form and hand it in to the surgery. Please ask at reception for a SCR opt out form

You are free to change your decision at any time by informing us at the practice.

Children will automatically have a Summary Care Record made for them. If an Opt out form is completed for a child the GP will consider the request.

I certify that the information I have provided is correct and consent to my personal and medical information being used as stated above.
Your signature: / Date:

NHS Organ Donor registration

Iwant to register on the NHS Organ Donor Register as someone whose organs/tissue may be used for transplantation after your death. please tick boxes that apply:
□Any of my organs and tissue or□Kidneys □Heart □Liver □Corneas □Lungs □Pancreas □Any part of my body
Signature confirming consent to Organ/Tissue donation
……………………………………………………………………… Date………………/…………………/………………

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:
or call direct on 0300 123 23 23

THANK YOU FOR YOUR HELP IN COMPLETING THIS FORM

Office use only

Registered by (initials) / EMIS No: / Usual DR:
Lifestyle coded: / Nurse-Imms: / Scanned: