New patient registration (over 16)

Would you like a new patient health check?

Yes

No

You will need to ring the surgery to book this within 1 week.

Please bring a sample of urine with you, in a clean container.

Patient’s Details

Please specify:

Surname:

Previous Surnames:

First Name(s)

Middle Name(s):

Preferred Name:

Gender

Male

Female

Indeterminate

NHS Number (if known):

Town and Country of birth:

Home Address:

Postcode:

Home Phone Number:

Mobile Phone Number:

Work Phone Number:

Preferred contact number:

Home

Mobile

Work

Have you ever served in the Armed Forces?

Yes

No

Are you the spouse or partner of anyone who has served in the Armed Forces?

Yes

No

Marital Status:

Occupation:

SMS and Email Messaging

We offer an extra service of SMS Messaging and emailing to patients. This is used to confirm appointments, to send messages about test results, inform you of upcoming health campaigns etc.

It should be understood that these are not secure methods of communication.

The only secure methods of communication are through Airmid or the NHS App as they allow two factor authentication.

If you are happy to communicate with us, there are certain conditions attached to use of the service.

Please read the statement below and should you wish to register for SMS messaging or emailing, provide your consent on each question:

I confirm that the telephone number given is my personal mobile and not a shared with any other person.
I consent to the Practice contacting me by text message for the purposes of appointment reminders, action needed following test results, health promotion and Practice updates.
It is my responsibility to keep the Practice updated with any changes to my mobile number and or email address.
I acknowledge that appointment reminders, appointment invitations and messages about test results are an additional service and that they may not be sent on all occasions. The responsibility for attending and cancelling appointments as well as contacting the Practice to obtain the results of recent tests still rest with me.
I can cancel the text message facility at any time. My number and email address will be used only for information about me – and not other family members.
Text messages and emails are generated using a secure facility, but I understand that they are transmitted over a public network onto a personal telephone and as such, may not be secure.

Can we leave messages on your phone?

Yes

No

Can we contact you by text?

Yes

No

Can we contact you by email?

Yes

No

Ethnicity

Do you speak English?

Yes

No

Do you read English?

Yes

No

First Spoken Language:

Emergency Contact / Next of Kin

Full Name:

Relationship to you:

Phone Number:

Are they your next of kin?

Yes

No

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

Yes

No

Lifestyle

Height:

Weight:

Diet:

E.g. low fat, balanced, vegetarian etc.

Smoking Status:

Current Smoker

Ex Smoker

Never Smoked

Please state how much exercise and what type of exercise you do per week:

Allergies

Do you have any allergies?

Yes

No

Medication

Current Medication:

Do you take any medication prescribed by a hospital?

Yes

No

Please specify the medication prescribed by a hospital:

Do you take any over the counter medication?

Yes

No

Please specify the over the counter medication:

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