Register with:

Please complete all areas in CAPITAL LETTERS and tick the appropriate boxes. Please ensure you SIGN and DATE your form.

NHS No (if Known):

Personal Details:

Title:
First Name:
Surname:
Previous Surname:
DOB:
Place of Birth:
Name of School/Nursery (for Children):
Previous GP:
Gender: / ☐Male ☐Female

Contact Details:

Home:
Mobile:
Work:
E-Mail:

Additional Details: (For children only)

Parent / Guardian Name
Parent / guardian DOB:

Additional Details about You

Marital Status:

Ethnicity:

White: ☐British ☐Irish ☐Gypsy or Irish traveller ☐Other White
Black: ☐African ☐Caribbean ☐Other Black
Mixed: ☐White&Black Caribbean ☐White&Black African ☐White&Asian
☐Other Mixed
Asian: ☐Indian ☐Pakistani ☐Bangladeshi ☐Chinese
Other(Please Specify):
Occupation:

Spoken Language:

English Speaker: ☐Yes ☐No
Spoken Language:
Interpreter Needed: ☐Yes ☐No
If yes what language:
(for Women Only) Have you had a Cervical Smear? ☐Yes ☐No
Please state where, when and the result
Please Ring 0121 465 1000 to inform disclaimer.

Next of Kin Details:

Name of Next of Kin:
Relationship to you:
Next of Kin Telephone Numbers:
Next of Kin Address(if Different From Above):

Carer Information(not needed for children)

Do you have a Carer? ☐Yes ☐No
If yes,
Are they registered at this practice? ☐Yes ☐No
Name:
Telephone Numbers:
Do you consent for your carer to be informed about your medical care?
☐Yes ☐No
Are you a Carer? (Only if you are a registered Carer) ☐Yes ☐No
If yes, do you look after someone who is a patient at this practice?
☐Yes ☐No
If Yes, what is their Name? :
Are they a ☐Relative ☐Friend ☐Neighbour

Please tell us about your smoking habits (not needed for children)

Do you Smoke? ☐Yes ☐No
If Yes, What do you primarily smoke: ☐Cigarettes ☐Cigar ☐Pipe ☐Rolls
How many do you smoke a day?…………
Would you like advice on quitting? ☐Yes ☐No
Are you Ex-smoker? ☐Yes ☐No

Please tell us about your alcohol consumption (not needed for children)

Do you drink Alcohol? ☐Yes ☐No
How many units? …………..

If YES then please answer these questions (Please circle your answer in the boxes)

How often do you have a drink containing alcohol? / Never / Monthly or less / 2- 4 times per month / 2-4 times per week / 4+ times per week
How many units of alcohol do you drink on a typical day when you are drinking? / 1 – 2 / 3 – 4 / 5 – 6 / 7 – 9 / 10+
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? / Never / Less than monthly / Monthly / Weekly / Daily or almost daily

Depending on your answers above you may be asked to complete an additionalquestionnaire.

Medical Details

In order to continue to receive your repeat medications you’ll need to bring in your re-order form from your previous GP.

Nominate Pharmacy

We have ETP functionality, this will allow us to send your prescription electronically to your preferred choice of pharmacy, and will also save you time in collecting your prescription from the surgery.
Nominated Pharmacy:

Vaccinations

Please bring in the Red Book of the child to update their vaccination history. If in case you do not have the Red Book please bring in a copy of the vaccinations had from your previous GP.
Are you allergic to any medicines? ☐Yes ☐No
If yes, please specify:
List other allergies (pollen, animal hair or certain foods. Please mark “none” if you have no other allergies that you know of

Accessible Information Standard

We want to get better at communicating with our patients. We want to make sure that you can read and understand the information we send you. If you find it hard to read our letters or if you need someone to support you at appointments, please let us know.
We want to know if you need information in braille, large print or easy read. We want to know if you need a British Sign Language interpreter or advocate. We want to know if we can support you to lip read or use a hearing aid or communication tool. We want to know if you need an interpreter for your appointments.
Do you have any communication needs?
☐Registered Partially Blind
☐Registered Blind
☐Deafness
☐Hearing Loss
☐Interpreter needed? State Language …………………………
Do you need a format other than standard print?
☐Require written information in large font
☐Require information in uncontracted Braille
☐Require information in contracted Braille
Do you have any special communication requirements?
☐Uses Hearing Aid
☐Uses hearing Loop
☐Uses Speech to text reporter
☐Uses Sign language
☐Uses Lip speaker
How do you prefer to be contacted?
☐By phone
☐By E-Mail
☐By SMS
☐By Letter

Patient Access Online

You will be able to register with our on-line service provider,through this you’ll be able to order your repeat medications, book appointments and view certain aspects of your medical record via the internet. This service is known as Patient Access.
(Children under 16 will be given Proxy-Access)
Would you like to have access to this service? ☐Yes ☐No

I wish to have access to the following online services (please tick all that apply):

  1. Booking appointments
/ 
  1. Requesting repeat prescriptions
/ 
  1. Limited access to parts of my medical record – Detailed Read Code Access
/ 
I wish to access my medical record online and understand and agree with each statement (tick)
  1. I have read and understood the information leaflet provided by the practice
/ 
  1. I will be responsible for the security of the information that I see or download
/ 
  1. If I choose to share my information with anyone else, this is at my own risk
/ 
  1. I will contact the practice as soon as possible if I suspect that my account has been accessed by someone without my agreement
/ 
  1. If I see information in my record that is not about me or is inaccurate, I will contact the practice as soon as possible
/ 
Need to provideMobile numberand Email address, not shared to another person.

Data Sharing

Do you consent to the shared NHS
Summary Care Record (SCR)? ☐Yes ☐No
Your Care Connected (YCC)? ☐Yes ☐No
Signed: Date:
Signed on behalf of patients(if applicable):
(e.g. for minors under 16 years old, adults lacking capacity)
For Office use only
Photo ID ☐ Type:…………………………….
(Aged 16 and over only)
Address ID ☐ Type:………………………………
Identity Verified By: