New patient registration (13 to 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: *

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:

This must not be a shared number

Preferred contact number:

Home

Mobile

Do either of your parents serve in the Armed Forces?

Yes

No

Please specify:

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

Please state:

Do you speak English?

Yes

No

Do you read English?

Yes

No

First Spoken Language:

Next of Kin

Full Name:

Phone Number:

Date of birth:

Relationship to you:

Lifestyle

Smoking Status:

Current Smoker

Ex Smoker

Never Smoked

We offer smoke cessation advice and treatment. Would you like support to give up smoking?

Yes

No

Stopping smoking is not easy. If you are a current smoker, below are some tips that may help you to quit smoking.

However, we have a stop smoking advisor, who can support you. Just book an appointment with one of our Practice Nurses.

Write a list of the reasons why you want to stop and keep them with you. Refer to them when tempted to light up.

Set a date for stopping and stop completely. (Some people prefer the idea of cutting down gradually. However, research has shown that if you smoke fewer cigarettes than usual, you are likely to smoke more of each cigarette, and nicotine levels remain nearly the same. Therefore, it is usually best to stop once and for all from a set date).

Tell everyone that you are giving up smoking. Friends and family often give support and may help you. Smoking by others in the household makes giving up harder. If appropriate, try to get other household members who smoke, or friends who smoke, to stop smoking at the same time. A team effort may be easier than going it alone.

Take one day at a time. Mark off each successful day on a calendar. Look at it when you feel tempted to smoke and tell yourself that you don’t want to start all over again.

Be positive. You can tell people that you don’t smoke. You will smell better. After a few weeks you should feel better, taste your food more, and cough less. You will have more money. Perhaps put away the money, which you would have spent on cigarettes, for a treat!

You can phone the free smoking helpline 0800 022 4 332 or get help by visiting NHS Quit Smoking.

How many did you smoke per day?

When did you stop?

Allergies

Do you have any allergies?

Yes

No

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

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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