First Name*

Surname*

Previous Surname

Date of Birth*

Postcode*

Address*

Sex*

Town of birth*

Country of Birth*

Home Number

Mobile Phone Number*

Work Phone Number

Email*

Can we contact you by text?

Can we contact you by email?

Please specify the ethnic group you consider you belong to

Do you read English?

Do you speak English?

First Language

Full Name of emergency contact

Relationship to you of emergency contact

Phone number of emergency contact

Are they your next of kin?

Do you give us permission to discuss your medical records with them?

Which of your medical records may we discuss with them?

Do you have any allergies?

Please specify what you are allergic to, what happens and when you had your first reaction

Do you have a carer?

Name of carer

Phone number of carer

Address of carer

Are you a carer for someone?

Height *

Weight *

How many do you smoke each day? *

How many did you smoke per day? *

When did you stop? *

Immunisation History

List any immunisations/vaccinations you have had

Please include dates

Medical History

Major illnesses

Please include dates

Past operations

Please include dates

Family History Illnesses

Please include dates

Electronic Prescribing

The Electronic Prescription Service (EPS) sends electronic prescriptions from GP practices to pharmacies. Eventually EPS will remove the need for most paper prescriptions.

Would you like to nominate a pharmacy for electronic prescribing? *

Name of pharmacy *

Which Practice/GP Surgery you are coming from?

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.

Signature *

Date

If you do NOT wish the NHS to share data from your health records for the purposes of research and planning, please opt out on the NHS website.

These are an electronic record of important patient information, created from GP medical records. They can be seen and used bu authorised staff only; in other areas of the health and care system involved in the patients care.

To Opt Out, visit www.digital.nhs.uk/scr

For more information on organ donation, please visit: www.organdonation.nhs.uk

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 on: www.blood.co.uk or call direct on 03001232323

This form collects your name, date of birth, email, other personal information and medical details. This is to confirm you are registered with the practice, to allow the practice team to contact you and also to update your medical records held by the practice and our partners in the NHS. Please read our Privacy Policy to discover how we protect and manage your submitted data.