New Patient Essential Information

Please take a few moments to complete this form and return it with your completed registration form. The answers which you give will allow us to plan what care you may need from us in the near future.

PATIENT DETAILS

Title: Mr / Mrs / Miss / Ms / Other ______First Name ______Surname ______

Telephone number ______Mobile ______

E-mailaddress: ______

We often communicate via SMS. If you do not wish to receive SMS alerts please tick 

Have you ever lived in England? Yes / No Have you ever been registered with a GP in the England? Yes / No

If you have ever been registered with a GP in England please provide registered address?

______

Approximate date: ______

Main language if not English______Do you require an Interpreter? Yes / No(9NU0)

Smoking Status

Lifelong non-smoker(1371) Ex-smoker (137S)  Current smoker(137R)Prefer not to say (137k)

If you are a current smoker you are damaging your health and it would be to your advantage to stop. We have a nurse led Smoking Cessation Service which is available by appointment

Alcohol consumption

Questions / Scoring System / Your score
0 / 1 / 2 / 3 / 4
How often do you have a drink that contains alcohol? / Never / Monthly or less / 2-4 times a month / 2-3 times a week / 4+ times a week
How many standard alcoholic drinks do you have on a typical day when drinking? / 1-2 / 3-4 / 5-6 / 7-8 / 10+
How often do you have 6 or more standard drinks on one occasion? / Never / Less than monthly / Monthly / Weekly / Daily or almost daily
Scoring: A total of 5 + indicates hazardous of harmful drinking / Total

I do not wish to provide this information (9k19)

Do you have any other Long Term Condition?

YesNo

If Yes, please list______

______

Do you have a continuing need for repeat prescriptions?

YesNo

If Yes, would you like us to send your prescriptions electronically to a Chemist of your choice?

Chemist name / address: ______

Do you require information to be provided in different formats?:

 Large print  Braille Other ______

Summary Care Record: If you wish to opt out of the Summary Care Record please tick here 

For information on Summary Care Records please speak to a member of staff

FOR ADMIN USE ONLY

Registration validation (to be completed by staff member accepting registration form to confirm information checked thoroughly):

ID seen? Utility seen? 

Type of ID ______Type of Utility ______

5 or Under – Red Book Supplied? 

Form checked and accepted by (Name) ______Date ___ / ___ / _____

Is this a New Registration  or a Re-registration [Existing EMIS No: ______Type of Registration: Full / Temp]

Registration completion (to be completed by staff member adding registration to EMIS):

Is patient aged 40 – 74?  Yes  No

Does Patient have pre-existing condition that would make them ineligible for NHS Health Check? (i.e. had a stroke, have heart disease, diabetes, kidney disease)  Yes  No

If patient in eligible age group without pre-existing condition please offer New Patient Health Check with HCA

Named Accountable GP ______(9NN60)

 Patient advised (67DJ) via New Patient letter

New Patient set up completed on EMIS (to be completed within 2 working days of receipt):

Initials ______Date ___ / ___ / _____

Documents scanned to patient record (to be completed within 2 working days of registration completion):

Initials ______Date ___ / ___ / _____

Reg Form Oct2017 v5