Personal Details
Please complete the table below:
First Name
Surname
Date of Birth
Sex
Height
Weight
Occupation
Mobile no
Email address
Name & contact no of emergency contact
Relationship to patient
Are you a carer
(If yes, please ask for Carers form from Reception) / Yes/ No
Female Patients
Number of children / Age / Age / Age / Age
Date of last Cervical Smear if known:
Recreational Habits
Smoking related questions to be completed for all patients over 14
Have you ever smoked? Yes/No
Ex-Smoker Date Stopped: ______
Current Smokers, please state amount smoked daily:
Cigarettes[] (number)
Cigars[] (number)
Pipe[] (ounce) / Medical History
Do you suffer any of the following conditions?
Yes/No / When diagnosed
Heart Disease
Stroke
Diabetes
Hypertension
Asthma
COPD
Family History
Have either of your parents, brothers or sisters had Angina or a Heart Attack before the age of 60?
YES / NO
If yes please give details:
Current Medication
Please list or Attach the repeat order form:
Allergies(Please list):
Other Information:
/
We would like to take your blood pressure when you register. If you have recent readings please advise:

RECORD OF PATIENT ETHNIC ORIGIN

Please state your first language: ______

Please advise if translator is required Yes/No

Please indicate your ethnic origin. This is not compulsory, but may help with your healthcare, as some health problems are more common in specific communities and knowing your origins may help with the early identification of some of these conditions.

Ethnic Origin / √
British or mixed British
Irish
Other white background
White and Black Caribbean
White and Black African
White and Asian
Other Mixed Background
Indian or British Indian
Pakistani or British Pakistani
Bangladeshi or British Bangladeshi
Other Asian Background
Caribbean
African
Other Black Background
Chinese
Other
Declined
Name / Signature / Date
FOR OFFICE USE ONLY
Photo ID seen (please circle): Passport Driving Licence Other (please state): …………….
Proof of Address: …………………………………………………………………………………………
Over 75 letterreqd? N/A YES
Stop Smoking Booklet Given: Yes No N/A
Person accepting Registration Form (please print name): ……..…………………………….
Date………………………………..

The Lee-on-the-Solent Medical Practice

Patient Contact Waiver

Dear Patient,

In accordance with the Data Protection Act there is a requirement that Practice Staff, when required to contact a patient on medical matters, can only speak to the person concerned. If anyone other than the patient answers the phone, the member of staff cannot reveal who is calling. This undoubtedly causes frustration and delays the passing of any messages to you. No medical information will be released without the completion of a separate Third Party Consent form, but it can be helpful for Practice Staff to leave messages on home numbers, mobile numbers and with household members asking you to return our call.

In an attempt to make things easier for you, could you please indicate the following:

  1. Are you happy if a message is left with a member of your household saying that you have received a call from the Surgery? Yes/No
  1. Are you happy for a message to be left on any answerphone you may have at your home address asking you to contact the Surgery? Yes/No
  1. Are you happy for a message to be left via voicemail on any mobile number that we hold for you? Yes/No
  1. Are you happy for an email to be sent from the Surgery to any email account that you have provided for all matters including any annual reviews? By providing this address you accept that other household members may be able to access the information we send if this is a shared account. Yes/No

In signing this statement I confirm that I have agreed to those options that I have circled above and recognise that this authorisation will remain in force for the duration of the time that I remain a patient of Dr Bell & Partners, or until such a time as I give notice that I wish to revoke any of the declarations that I have made above.

Signature______

Date: ______

Name (please print full name): ______

Address: ______

______Emails address: ______

Tel No: ______Mobile No: ______

The Lee-on-the-Solent Medical Practice

Third Party Consent Form

Patients name: ______

Patients Date of Birth: ______

Patients address:______

______

______

Telephone Number: ______

Named Third Party: ______

Third Party Telephone Number: ______

I hereby consent to Lee-on-the-Solent Health centre releasing medical information, and discussing my care and medical records, with the above named person.

Signed (patient): ______

Date: ______

Witnessed by (print name): ______

Signed by witness: ______

Date: ______