New patient registration form – Stoke Gifford & Conygre Medical Centre

Please complete the form below as fully as possible to allow us to process your application as efficiently as possible.

Please do not use this form if you are trying to register as a Temporary patient. Please contact Reception instead

Your contact details

NHS Number

Get help to find your NHS number online

Title(Required)

Please enter your title

First name(s)(Required)

Surname(Required)

Previous surname (if applicable)

Date of Birth(Required)

Male/Female(Required)

Male

Female

Current home address (inc. flat number if appropriate)(Required)

Current postcode(Required)

Home Telephone(Required)

Mobile Telephone

Work Telephone

Enter Email Confirm Email

Your Town and Country of birth(Required)

Are you ordinarily resident in the UK(Required)

Yes

Have you returned to the UK from abroad?(Required)

Yes

Please give the date you left the UK

Please give the date of your return to the UK

Are you registering with the NHS for the first time in the UK?(Required)

Yes

Please give the date you came to the UK

I live in another EEA country, or I have moved to the UK to study or retire, or I live in the UK but work in another EEA member state.

Yes

Non-UK European Health Insurance Card (EHIC), Provisional Replacement Certificate (PRC) details and S1 forms

You only need to complete this section if you live in another EEA country, or have moved to the UK to study or retire, or if you live in the UK but work in another EEA member state. Do not complete this section if you have an EHIC issued by the UK.

Do you have a non-UK EHIC or PRC?

If you select yes please complete the additional details from your EHIC card that will appear below.

Yes

If yes, please enter details from your EHIC or PRC below:

3: Name(Required)

Country Code(Required)

4: Given Names(Required)

5: Date of Birth(Required)

6: Personal Identification Number(Required)

7: Identification number of the institution(Required)

8: Identification number of the card(Required)

9: Expiry Date

PRC validity period (a) From:

PRC validity period (b) To:

Supplementary questions - These questions and the patient declaration are optional and your answers will not affect your entitlement to register or receive services from your GP.

PATIENT DECLARATION for all patients who are not ordinarily resident in the UK

Anybody in England can register with a GP practice and receive free medical care from that practice. However, if you are not ‘ordinarily resident’ in the UK you may have to pay for NHS treatment outside of the GP practice. Being ordinarily resident broadly means living lawfully in the UK on a properly settled basis for the time being. In most cases, nationals of countries outside the European Economic Area must also have the status of ‘indefinite leave to remain’ in the UK.

Some services, such as diagnostic tests of suspected infectious diseases and any treatment of those diseases are free of charge to all people, while some groups who are not ordinarily resident here are exempt from all treatment charges.

More information on ordinary residence, exemptions and paying for NHS services can be found in the Visitor and Migrant patient leaflet, available from your GP practice.

You may be asked to provide proof of entitlement in order to receive free NHS treatment outside of the GP practice, otherwise you may be charged for your treatment. Even if you have to pay for a service, you will always be provided with any immediately necessary or urgent treatment, regardless of advance payment.

The information you give on this form will be used to assist in identifying your chargeable status, and may be shared, including with NHS secondary care organisations (e.g. hospitals) and NHS Digital, for the purposes of validation, invoicing and cost recovery. You may be contacted on behalf of the NHS to confirm any details you have provided.

Please select one of the following options(Required)

I understand that I may need to pay for NHS treatment outside of the GP practice

I understand I have a valid exemption from paying for NHS treatment outside of the GP practice. This includes for example, an EHIC, or payment of the Immigration Health Charge (“the Surcharge”), when accompanied by a valid visa. I can provide documents to support this when requested

I do not know my chargeable status

I declare that the information I give on this form is correct and complete. I understand that if it is not correct, appropriate action may be taken against me.

I agree to the statement above

A parent/guardian should complete the form on behalf of a child under 16.

S1 Form

Please tick if you have an S1 (e.g. you are retiring to the UK or you have been posted here by your employer for work or you live in the UK but work in another EEA member state).

Yes I have an S1 form

Please give your S1 form to the practice staff. How will your EHIC/PRC/S1 data be used? By using your EHIC or PRC for NHS treatment costs your EHIC or PRC data and GP appointment data will be shared with NHS secondary care (hospitals) and NHS Digital solely for the purposes of cost recovery. Your clinical data will not be shared in the cost recovery process. Your EHIC, PRC or S1 information will be shared with The Department for Work and Pensions for the purpose of recovering your NHS costs from your home country.

Your next of kin

Next of kin title(Required)

Please enter title

Next of kin first name(s)(Required)

Next of kin surname(Required)

Male/Female(Required)

Male

Female

Relationship to you:(Required)

Contact number:(Required)

Previous address details

Please enter your previous address(Required)

Please help us trace your previous medical records by providing this information.

Previous postcode(Required)

Previous GP name and address(Required)

Please help us trace your previous medical records by providing this information.

Were you ever registered with an Armed Forces GP?

These questions are optional and your answers will not affect your entitlement to register or receive services from the NHS but may improve access to some NHS priority and service charities services.

Please indicate if you have served in the UK Armed Forces and/or been registered with a Ministry of Defence GP in the UK or overseas

Regular

Reservist

Veteran

Family Member (Spouse, Civil Partner, Service Child)

Address before enlisting

Postcode

Service or Personnel number

Enlistment date

Discharge date (if applicable)

About you

Your Ethnicity

Please state your ethnicity

Your Religion

Your Housing

Your Employment

Please enter your occupation

Communication needs

What is your first language?

Do you need an interpreter?

Yes

Language of interpreter

Do you have any specific communication needs? By leaving this section blank we will not record the need for alternative communication methods in your record.

Do you have a learning disability?(Required)

Yes

Please give further information on your learning disability

Carers

A Carer is someone, who, without payment, provides help and support to a partner, child, relative, friend or neighbour, who could not manage without their help. This could be due to being elderly, physical or mental illness, addiction or disability. We would be grateful if you could complete the following questions for the Practice Carer’s Register. The register enables the practice to proactively manage carer’s needs with the practice and to consider the provision of services to carers. The practice will also ensure that all patients who are carers are informed of and supported in joining the local carer’s link.

Are you a carer?

Yes - Informal/Unpaid carer

Yes - Occupational/Paid Carer

Name of the person you care for:

First Last

What is your relationship with the person you care for?

DOB of the person you care for:

Address of the person you care for:

Telephone number of the person you care for:

NHS number of the person you care for:

Are you being cared for?

Yes

Name of your carer:

First Last

What is your relationship with your carer?

DOB of your carer:

Address of your carer:

Telephone number of your carer:

NHS number of your carer:

If you consent to your Carer being informed of any medical information about you which is held at the practice, please check the box below; if NOT leave blank

I am happy for my carer to be informed of any medical information about me which is held by the practice.

Medical information

Are you registered disabled?(Required)

Yes

Please give further information here

Have you suffered from any of the following conditions?(Required)

Please state the type of cancer

Please let us know which mental health problem you suffer from or have received treatment for in the past

Depression

OCD

Anxiety

Bipolar disorder

Please state the year when you were first diagnosed (or approximate date)

Do you have any other mental health problems? If yes, please state these below

ALLERGIES: Please list any allergies or sensitivities you have including drug allergies below(Required)

Please enter 'N/A' if you have no allergies to report

Please list any immunisations or vaccinations you have had

Any other conditions, operations or hospital admission details:

If you are currently under the care of a Hospital or Consultant outside our area, please tell us here:

Family history

Please record any significant family history of close relatives with medical problems and confirm which relative e.g. mother, father, brother, sister, grandparent

Please give any details if you have ticked any of the above

Current medication

Please check and include as much information about your current medication below Please give us your previous repeat medication list if possible and a medication review appointment may be needed(Required)

Please enter 'N/A' if taking no medication

Your lifestyle

How many times a week do you exercise?

Alcohol consumption - How many units of alcohol do you consume in a week?

Approximately - 1 drink = 1/2 pint of beer or 1 glass of wine or 1 single spirits. 1 unit of alcohol = 10cc of alcohol. So, a small glass (125cc) of 12% wine is 12.5 * 0.12 = 1.5 units. Find out more about alcohol units on the NHS website

How often do you have a drink containing alcohol?

How many units of alcohol do you drink on a typical day when you are drinking?

How often have you had 6 or more units if female, or 8 or more if male, on a single occasion in the last year?

Part one score

A score of less than 5 indicates lower risk drinking

Alcohol consumption – Part Two

Scores of 5 or more in Part 1 requires the following 7 questions to be completed

How often during the last year have you found that you were not able to stop drinking once you had started?
Never
Less than monthly
Monthly
Weekly
Daily or almost daily

How often during the last year have you failed to do what was normally expected from you because of your drinking?
Never
Less than monthly
Monthly
Weekly
Daily or almost daily

How often during the last year have you needed an alcoholic drink in the morning to get yourself going after a heavy drinking session?
Never
Less than monthly
Monthly
Weekly
Daily or almost daily

How often during the last year have you had a feeling of guilt or remorse after drinking?
Never
Less than monthly
Monthly
Weekly
Daily or almost daily

How often during the last year have you been unable to remember what happened the night before because you had been drinking?
Never
Less than monthly
Monthly
Weekly
Daily or almost daily

Have you or somebody else been injured as a result of your drinking?
No
Yes, but not in the last year
Yes, during the last year

Has a relative or friend, doctor or other health worker been concerned about your drinking or suggested that you cut down?
No
Yes, but not in the last year
Yes, during the last year

Score - part 2
0 – 7 Lower risk, 8 – 15 Increasing risk, 16 – 19 Higher risk, 20+ Possible dependence.

Total Score for alcohol questionnaire

Smoking

What is your smoking status?
Never smoked
Ex-smoker
Smoker

Do you use an e-Cigarette?
No
Ex-user
Yes

How many cigars/ cigarettes or e-cigarettes do you smoke per day?

Would you like advice/help on quitting?
Yes
No
For further information please see: www.nhs.uk/smokefree

Height and weight

Your height:

Your weight:

Waist circumference

For patients aged 65 and over or those with a chronic disease (e.g. asthma or diabetes)

Have you had a flu vaccination? If yes, please give the date below.

Have you had a pneumococcal vaccination? If yes, please give the date.

Women only

Have you ever had a cervical smear?
Yes
No

Please state when, where and the result

Do you use any contraception?
Yes
No
If needed, please book an appointment

Do you have a coil or implant in situ?
Yes
No

Date inserted

Are you currently pregnant or think you may be?
Yes
No

Expected due date

Have you had any children?
Yes
No

Please give the dates of birth of your children

Have you had a hysterectomy?
Yes
No

Which type of hysterectomy have you had?

When was the date of your hysterectomy?

Students only

Students are at risk of certain infections including mumps, meningitis and sexually transmitted infections, as well as mental health issues including stress, anxiety and depression. Please see www.nhs.uk/Livewell/Studenthealth

I am less than 24 years old and have had two doses of the MMR Vaccination
Yes
No
Unsure

I am less than 25 years old and have had a Meningitis C Vaccination
Yes
No
Unsure

Electronic prescribing

If you would like your prescriptions to be sent electronically, please provide details of the pharmacy you would like to use:

Patient participation group

We are committed to improving the services we provide. The Patient Participation Group is a mechanism for us to gain valuable feedback from our patients about their experiences, views and ideas for improving our services.

Would you like to be involved in our Patient Participation Group?
Yes
No

Living will

Do you hold a living will?
Yes
No
(A Living Will is documentation regarding your personal wishes in respect of medical intervention at the time of serious illness)

NHS patient information sharing - Summary Care Record

If you are registered with a GP practice in England you will already have a Summary Care Record (SCR), unless you have previously chosen not to have one. It will contain key information about the medicines you are taking, allergies you suffer from and any adverse reactions to medicines you have had in the past.

Information about your healthcare may not be routinely shared across different healthcare organisations and systems. You may need to be treated by health and care professionals that do not know your medical history. Essential details about your healthcare can be difficult to remember, particularly when you are unwell or have complex care needs.

Having a Summary Care Record can help by providing healthcare staff treating you with vital information from your health record. This will help the staff involved in your care make better and safer decisions about how best to treat you.

This section of the form covers the Summary Care Record. If you would like to know more about these things, please see the following link: NHS Health Records

NHS Summary Care Record(Required)
You have the choice of what information you would like to share and with whom. Authorised healthcare staff can only view your SCR with your permission. The information shared will solely be used for the benefit of your care.
Express consent for medication, allergies and adverse reactions only
Express consent for medication, allergies, adverse reactions and additional information
Express dissent for Summary Care Record (Opt out) – Patient does not want a summary care record and fully understands the risks involved with this decision. Select this option, if you DO NOT want any information shared with other healthcare professionals involved in your care.

NHS Patient information sharing - GP records

When you visit an NHS or social care service, information about you and the care you receive is recorded and stored in a health and care record. This is so people caring for you can make the best decisions about your care.

Sharing your health record will ensure you receive the best possible care and treatment wherever you are and whenever you need it. Choosing not to share your health record could have an impact on the future care and treatment you receive.

If you would like to know more about these things, please see the following link: NHS Health Records

Do you consent to your GP Practice sharing your health record with other organisations who care for you?(Required)
Yes
No

Do you consent to your GP Practice viewing your health record from other organisations that care for you?(Required)
Yes
No

Would you like to register for online services?(Required)
You can book/cancel appointments, order prescriptions and see your medical record and results online
Yes
No

Contact preference consent(Required)
I agree that I may be contacted from time to time, via email and/or SMS with practice news, advice about my health and/or appointment reminders.
Yes I consent to be contacted via email and/or SMS
No I do not wish to be contacted via email and/or SMS

Signature

Please enter your full name(Required)

Today's date
Day
Month
Year

Not for urgent medical help(Required)
Yes, I understand this form is NOT for urgent medical help

Consent(Required)
By submitting your details you are consenting to providing this information for improving our services to you. The data you supply on this form will be securely stored on our website, which is hosted by a third party. We will retain this information on the website for no longer than 7 calendar days. your contact details will not be sold or shared with a third party. I understand I can revoke this consent at anytime by contacting the practice. Our privacy policy can be viewed on this website.
I agree to the privacy policy.

Comments
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