New Patient Registration

Please complete our online form

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Patient's Details

Information we need to register you with the practice
Please note all fields marked with a * are mandatory for your registration

Title: *

Gender: *

Are you happy for us to contact you by letter? :

Are you happy for us to contact you by text?:

Please Note: We are part of phase 4 of the Electronic Prescription Service (EPS) which will mean that almost all our prescriptions will be processed electronically.

Ethnicity & Religion

Please specify the ethnic group you consider you belong to: *

Your Religion:

Do you speak English?:

Do you read English?:

Do you require an interpreter?:

Previous Details

Please include postcode

Are you registering for the first time in the UK? : *

Are you returning from abroad?: *

If you are from abroad

Please use this date format: DD/MM/YYYY

Refugee: *

Asylum Seeker: *

Do you require an interpreter when you see the doctor/nurse?: *

Are you returning from abroad? : *

If you are returning from abroad

Previously been registered with the NHS in the UK

Please use this date format: DD/MM/YYYY

Have you ever served in the armed forces?

Have you ever served in the armed forces?: *

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:

Footnote: 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

Supplementary Questions

Please select one of the following statements::

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 at reception. Alternatively for more information go to the NHS Website

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.

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.

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

European Economic Area (EEA) Country

LIST OF EEA COUNTRIES

Do you live in another EEA country, or have moved to the UK to study or retire, or live in the UK but work in another EEA member state?:

Do you have a non-UK European Health Insurance Card (EHIC) or a Provisional Replacement Certificate (PRC) ?:

If you are visiting from another EEA country and do not hold a current EHIC (or Provisional Replacement Certificate (PRC))/S1, you may be billed for the cost of any treatment received outside of the GP practice, including at a hospital.

Please enter the details from your EHIC or PRC below.

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.

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Lifestyle

Would you like weight management advice?:

Smoking Status: *

Do you use e-cigarettes?:

Smoking is harmful to your health and we offer clinics and advice to help you give up. Would you like more information on this service?: *

Your Personal Alcohol Consumption

How often did you have a drink containing alcohol in the past year?: *

How many drinks containing alcohol did you have on a typical day when you were drinking in the past year?: *

How often did you have six or more drinks on one occasion in the past year?: *

Audit Score Result

you have a score of

If you are drinking less than 14 units of alcohol per week, then your drinking is within the UK Chief Medical Officers' low risk drinking guidelines.

But if you are drinking regularly at or above the low risk guidelines of 14 units a week, or, you are drinking six or more units - if you are female - or eight or more units - if you are male - in one single session (binge drinking), please consider the increased serious risks to your health being caused by your current drinking pattern.

Carers

Do you have a carer?: *

Are you a carer for someone?: *

Do you give us permission to discuss your medical record with your carer?: *

Additional Needs

Are you registered disabled?:

Do you have any communication/information needs relating to a disability, impairment or sensory loss?:

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Adult Females

Please use this date format: DD/MM/YYYY.

Was it done at:

Do you currently have a pessary fitted?:

Please specify type of pill, implant etc

Do you use a coil?:

Allergies

Do you have any allergies?: *

Medical History

Please include dates.

Have you ever suffered from any of the following?:

Please include dates.

How do you describe your sight?:

How do you describe your hearing?:

Over 75 years old?

The Department of Health has advised that all patients of 75years and older have a named and accountable GP to oversee their care. Please ask the name of the GP assigned to oversee your care. Please note this does not prevent you from seeing the GP of your choice.

Immunisation History

Please give the dates you last had the following immunisations:

Next of Kin

Please ensure your Next of Kin have consented to have these details stored on your medical record.

Do you give us permission to discuss your medical records with them?:

Is your Next of Kin your emergency contact?:

Emergency Contact

Please ensure your emergency contact person have consented to have these details stored on your medical record.

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Summary Care Record

Summary Care Record (SCR)

The Summary Care Record (SCR) system is designed to help both your GP and any emergency staff you contact when the surgery is closed to treat your health needs more efficiently.

Your information will be shared between your GP practice, our local hospital and Out Of Hours service. This will enable your GP surgery to access results and any visits you have at the hospital quickly and efficiently, but it also means that if you have an emergency and contact the Out Of Hours service or visit A&E they will have access to your current medications as well as allergies and are better able to treat you.

SCR Options: *

If you do not return this form, a Summary Care Record will be created for you based on implied consent

National data opt out

Information about your health and care helps us to improve your individual care, speed up diagnosis, plan your local services and research new treatments. In May 2018, the strict rules about how this data can and cannot be used were strengthened. The NHS is commited to keeping patient information safe and always being clear about how it is used. You can choose whether your confidential patient information is used for research and planning.

To find out more visit NHS - Your NHS Data Matters.

Make your choice at Your NHS Data Matters - Manage Your Choice.

Connecting Care Record

This is a local system (Bristol) that will enable hospital and out of hours clinicians to be able to view key information from your record.

CCR Options: *

Patient Participation Group

We have an active PPG at the surgery who represent our patients' views. Learn more about the PPG.

Would you be interested in joining?:

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NHS Organ Donor registration

More information on Organ Donation

NHS Blood Donor registration

If you would like to join the NHS Blood Donor Register as someone who may be contacted and would be prepared to donate blood, please visit their website or call direct on 03001232323

What happens to my information?

Personal and medical information about patients registered at this practice are primarily kept electronically, although some is kept in paper form. Some information will be sent to hospital consultants and other health professionals to whom you are referred by your GP in order to provide continued healthcare and obtain treatment for you.

We sometimes use accredited suppliers for our communication with you, for example when we send recall letters for review clinics or medication reviews. All suppliers we use are checked carefully to ensure they comply with strict confidentiality protocols.

To ensure the security of all patient information, all staff that has access to your records is covered by confidentiality clauses in their contracts and the Data Protection Act and the Freedom of Information Act. Our guiding principle is that we hold your records in strict confidence.

I certify that the information I have provided is correct and consent to my personal and medical information being used as stated above.

Privacy Consent

This form collects personal and medical information about you. We use this information to allow the practice team to contact you. Please read our Privacy Policy to discover how we protect and manage your submitted data.

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New Patient Registration

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Summary Care Record (SCR)

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