Type of ID
Date
Staff initials
NEW PATIENT REGISTRATION FORM
UNDER 18 FORM
Welcome to The Beacon Health Group, as part of the registration process please fill in the questionnaire as accurately as possible as it will become part of you medical record.
Title: / Mr / Mrs / Ms / Miss / Dr / Rev. / Sir / gENDER:First Name: / Surname:
Previous Surname(s): / D.O.B: / Post Code:
Address:
Telephone - Home: / Telephone - Mobile:
Telephone - Work: / Consent to SMS
(this allows us to send you appointment notifications, free of charge)
Yes No
Ethnic Origin: / Parent/Guardian details:
Main Spoken Language:
Second Spoken Language:
Height: weight:
Have you had or are you suffering from any of the following conditions? Please tick any that apply
High blood pressure / Asthma or bronchitis
Diabetes / Heart disease
Mental health problems
Other – please specify
Do you have any allergies? If yes, please specify.
Has anyone in your immediate family (aged under 65) suffered from any of the following conditions? Please tick any that apply;
High blood pressure / Stroke / Mental health problems
Heart disease / Diabetes / Cancer (please specify)
PLEASE COMPLETE IN AS MUCH DETAIL AS POSSIBLE
Age / Injection / Yes/No / Date2 months / 5-in-1 (DTaP/IPV/Hib) vaccine–
Pneumococcal (PCV) vaccine
Rotavirus vaccine
Men B vaccine
3 months / 5-in-1 (DTaP/IPV/Hib) vaccine, second dose
Men C vaccine
Rotavirus vaccine, second dose
4 months / 5-in-1 (DTaP/IPV/Hib) vaccine, third dose
Pneumococcal(PCV) vaccine, second dose
Men B vaccinesecond dose
12-13 months / Hib/Men C booster, Men C(second dose) and Hib (fourth dose)
Measles, mumps and rubella (MMR) vaccine,
Pneumococcal (PCV) vaccine, third dose
Men B vaccinethird dose
2, 3 and 4 years plus school years one and two / Children's flu vaccine(annual)
From 3 years and 4 months (up to starting school) / Measles, mumps and rubella (MMR) vaccine, Second dose
4-in-1(DTaP/IPV)pre-school booster
12-13 years (girls only) / HPV vaccine
13-18 years / 3-in-1(Td/IPV)teenage booster, MenACWY vaccine
Allocated GP: Please be aware that you will be allocated a named GP within the Practice who will be responsible for your overall care; however you can still choose to see any GP at the Practice.
Please indicate that you have read and understood the leaflets regarding Summary Care Records (SCR) and Care Data
We ask that you read our appointment schedule and our procedure for appointments not attended
Patient Participation Group: Would you like to help shape the way the practice develops, share your views on how services are run and / or give constructive feedback? Why not join our Patient Participation Group? Further information can be found on our website or ask at reception for a form
We have several online services available such as: Ordering repeat prescriptions, booking and cancelling appointments, submitting questions & messages. To access these online services you will need a user name and password which will be issued to you upon registration. Usernames and password are activated within 24 hours of registration and should be kept private to prevent un-authorised access to your medical information.
I have read and fully understood the information within the New Patient registration Pack.
And I have filled in the details above to the best of abilities and understand that all information used will be used to form part of my medical history.
Signed ……………………………………………………………Date…………………………………………………………………………..