New Patient Registration Patient DetailsTitle Mr Mrs Miss Ms Mx Dr Other NHS Number Optional Surname First Name Middle Name Optional Previous Surname Optional Date of Birth Day Month Year Gender at Birth Female Male Gender Identify, if different from above: Optional EthnicityPlease SelectWhite – BritishWhite – IrishWhite – TurkishWhite – GreekWhite – KurdishWhite – OtherAsian – IndianBritish IndianAsian – PakistaniBritish PakistaniAsian BangladeshiAsian – OtherBlack – CaribbeanBlack – AfricanBlack – OtherMixed – BritishMixed CaribbeanMixed – AfricanMixed – White & AsianMixed – OtherEthnic – ChineseEthnic – FilipinoEthnic – VietnameseEthic – OtherI do not wish to discloseTown and Country of Birth Current Home Address Street Address Address Line 2 City Postcode Telephone NumberEmail Enter Email Optional Confirm Email Optional If you are applying on behalf of a childWho has the legal responsibility for the child..Full Name Optional Contact Number OptionalRelationship to Child Optional Is there social care involvement? Yes Optional No Optional If yes, please state involvement: Optional Please help us trace your previous medical records by providing the following information:Your previous address in the UK Street Address Address Line 2 City Postcode Name of previous GP practice while at that address Address of previous GP practice Street Address Address Line 2 City ZIP / Postal Code If you are from abroadYour first UK address where registered with a GP Street Address Optional Address Line 2 Optional City Optional Postcode Optional If previously resident in UK, date of leaving Day Optional Month Optional Year Optional Date you first came to live in the UK Day Optional Month Optional Year Optional Were you ever registered with an Armed Forces GPPlease indicate if you have served in the UK armed forces and/or been registered with a ministry of defence GP in the UK or oversees: Regular Optional Reservist Optional Veteran Optional Address before enlisting: Street Address Optional Address Line 2 Optional City Optional Postcode Optional Service or Personnel number: Optional Enlistment date: Day Optional Month Optional Year Optional Official discharge date: Day Optional Month Optional Year Optional Next of KinFull Name Relationship to you Telephone NumberAddress Street Address Optional Address Line 2 Optional City Optional Postcode Optional AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Optional CarersDo you have a carer? Yes No Name of Carer Contact NumberAre you a carer? Yes No If yes, Please provide the name of person you care for if registered at this Practice Optional Communication NeedsWhat is your main spoken language? Do you speak English? Yes No Do you read English? Yes No Are you a British Sign Language user? Yes No Do you require an interpreter for attending appointments? Yes No please specify language Do you have any specific information or communication needs? If so, please specify how we can meet these for you (e.g. large print, Braille, easy read communications) OptionalAbout YouSmoking Status Current Smoker Ex Smoker Never Smoked What do you smoke? e.g. Cigarettes, Vape, CigarsHow many do you smoke per day? Are you interested in advice on how to quit? Yes No Please state how much exercise and what type of exercise you do per week OptionalDo you have any current health problems? OptionalDo you have any allergies? Yes No Please specify what you are allergic to, what happens and when you had your first reactionMedical HistoryMajor Illnesses OptionalPlease include datesPast Operations OptionalPlease include datesFamily History Illnesses OptionalPlease include datesCurrent MedicationDo you take any regular medication? Yes No Please list your medication/sMedicationDose Add RemovePlease nominate a pharmacy so your prescriptions can be sent to them electronically Summary Care RecordThis record will contain summary information about any medicines you are taking, allergies you suffer from and any bad reactions to medicines you have had to ensure those caring for you have enough information to treat you safely. Your Summary Care Record will be available to authorised healthcare staff providing you with care anywhere in England, but they will ask your permission before they look at it. This means that if you have an accident or become ill away from home, healthcare staff treating you will have immediate access to important information about your health.Do you consent to having a Summary Care Record? Yes No Communication from the PracticeDo you consent to receive the following types of communication from the Practice? Tick all that apply Email Optional Text Messages Optional Answering Machine messages Optional Online AccessWould you like us to create an online services account for you?* Yes No I wish to have access to the following online services (please tick all that apply): Booking appointments Requesting repeat prescriptions Access to detailed medical record Full access to medical record I wish to access my online services and understand and agree with each statement I have read and understood the information provided by the practice I will be responsible for the security of the information that I see or download If I choose to share my information with anyone else, this is at my own risk If I suspect that my account has been accessed by someone without my agreement, I will contact the practice as soon as possible If I see information in my record that is not about me or is inaccurate, I will contact the practice as soon as possible Your Medical Information – Sharing Your DataUnder the General Data Protection Regulations (GDPR), we have a responsibility to keep your medical records confidential. We need your consent to share this with other authorised health professionals involved in your care or in planning your care. You can find more information on the website at www.nhs.uk/your-nhs-data-matters. Please see the privacy notice on our website for more information on how your data is held and used by the practice. The NHS wants to make sure you and your family has the best care now and in the future. Your health and adult social care information supports your individual care. It also helps us to research, plan and improve health and care services in England. There are very strict rules on how this data can and cannot be used, and you have clear data rights. We are committed to keeping patient information safe and will always be clear on how it is used. You can choose whether or not your confidential patient information is used for research and planning. If you do not wish your information to be used in this way please opt-out by visiting NHS: Your Data Matters or by calling 0300 303 5678. The practice is unable to record this for you.NHS Organ Donor registrationFor more information on organ donation please visit: www.organdonation.nhs.ukNHS Blood Donor registrationIf 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 03001232323SignaturePlease upload ID and proof of address Optional Drop files here or Select files Max. file size: 50 MB. Declaration I certify that the information I have provided is correct and consent to my personal and medical information being used as stated above. Signature Your Full NameDate Day Month Year If signed on behalf of patient: ( your full name and relationship to patient) Optional