New Patient Registration Form

Please have all the following information ready before completing this form.

Blood Pressure - we require 2 readings. If you do not have your own blood pressure machine these are available for use at the surgery or in local pharmacies.

Veterans - Enlistment date, Discharge date, Address prior to service

Confidentiality

Confidentiality is the cornerstone of health care and central to the work of everyone working in general practice. All information about patients is confidential; from the most sensitive diagnosis to the fact of having visited the surgery or being registered as a patient. All patients can expect that their personal information will not be disclosed without their permission exceptional circumstances, when somebody is at grave risk of serious harm. The duty of confientiality owed to a personunder the age of sixteen is as great as the duty owed to any other person.

Please find further details regarding your registration with the surgery in the following policies which can be found on our website: New patient Registration Policy, Zero Tolerance Policy, Complaints Policy.

Last Updated: 02/10/2024

Contact Details

Mobile numbers are our preferred method of communication.

Note: We can have mobile numbers of parents on child records until the age of 16 years old when they will be removed. A young person can contact us with their own mobile number after this date. A child from 11 years old can request to be communicated with directly, but a GP would need to review and approve this request.

It is your responsibility to keep us updated with any changes to your telephone number, email and postal address. We may contact you with appointment details, test results, health campaigns, or Patient Participation Group details. If you do not consent to being contacted by SMS or Email please opt out in the form below.

Full Name *

Previous Surname (If applicable)

Date of Birth *

Marital Status *

NHS Number (If you have had a previous GP you will find this on letters/prescriptions or at www.nhs.uk/find-nhs-number

Occupation *

Religion

Gender *

Language Spoken *

Are you happy for this information to be recorded on your medical records? *

Yes No

Is your gender the same as the sex you were given at birth? *

Sexual Orientation *

Are you happy for this information to be recorded on your medical records? *

Yes No

Telephone Number - Mobile numbers are our preferred method of communication. *

I consent to be contacted by SMS on this number *

Health Questionnaire

Medication

Please make sure you have at least 1 month supply of medication from your previous surgery - until this form is processed you will need to get medication items from your previous surgery.

You will need to make an appointment with our clinical pharmacist for your 1st prescription from this surgery.

Please make sure you have at least 1 month supply of medication from your previous surgery - until this form is processed you will need to get medication items from your previous surgery. You will need to make an appointment with our clinical pharmacist for your 1st prescription from this surgery. I have read and understand the information regarding my medications *

Yes No

If you are pregnant please provide your estimated delivery date

Blood Pressure - 2 readings are required If you don't have a home Blood Pressure machine you can access these at your local pharmacy or in our waiting area. *

If you are a current smoker or user of Vapes and would like help to quit, please tick here.

Yes No

The recommended weekly intake of alcohol should not exceed 14 units for a female, 21 units for a male. If you would like further advice regarding your alcohol consumption please book an appointment with a practice nurse. You can calculate your consumption levels here https://alcoholchange.org.uk/alcohol-facts/interactive-tools/unit-calculator

Online Access to your Health Record

Download the NHS App for online access to book/amend/cancel appointments, view medication and view your coded medical record. Proxy online access can be granted if certain criteria are met. A child from 11 years old can request online access, but a GP would need to review and approve the request.

HMS Armed Forces

There are certain referral pathways and services that are offered specifically to ‘veterans’ but this cannot be done if your GP doesn’t know about you.

Being flagged as a veteran means you are more likely to receive specialist veteran care and consideration, and GPs can refer you to specialist veteran services if you need them

Please copy this information, hand it in to reception or ask a friend or family member to do this for you. The receptionist will ensure it is dealt with correctly

Click here for more information Veterans Support - Whitley House Surgery

Enlistment Date

Discharge Date

Place Where Stationed

I consent to a 'history relating to military service' code adding to my record

Yes No

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New Patient Registration Form

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