New Patient Registration Form - Attleborough Surgeries

To register at our GP Practice please submit this health questionnaire. Please then visit either surgery with your photo ID and proof of address to verify your identity (a driving license will meet both criteria).

Non-urgent advice: Patient Notice

Please provide us with as much information about yourself as you can so that the health records we hold for you are up to date.

Blood Pressure

Please use the machine in our waiting room to record your blood pressure and pulse rate or if you have your own BP monitor at home please record your readings below.

BP Reading Optional

Pulse Rate Optional

Contact Details

Title

First Name

Do you have a middle name?

Yes

Middle Name

Surname

NHS Number (if known) Optional

Date of Birth

Day

Month

Year

Full Address

Street Address Address Line 2 City Postcode

Mobile Number

Home Number Optional

Work Number Optional

Enter Email Confirm Email

Gender Identity

Gender at Birth

SMS Consent

I consent to receive text messages from Attleborough Surgeries

I do NOT consent to receive text messages from Attleborough Surgeries

Email Consent

I consent to receive email communications from Attleborough Surgeries

I do NOT consent to receive email communications from Attleborough Surgeries

Preferred Method of Communication

Letter

SMS text message

No preference

Next of Kin

Full Name

First Last

Contact Number

Email Address

Enter Email Optional Confirm Email Optional

Full Address

Street Address Optional Address Line 2 Optional City Optional Postcode Optional

Relationship to Patient

GP History

Please help us trace your previous medical records by providing the following information

Previous GP Practice

Your Previous Address

Street Address Address Line 2 City Postcode

Previous Address if from abroad

Street Address Optional Address Line 2 Optional City Optional Postcode Optional

Date of Leaving UK

Date You First Lived in UK

Background

Country of Birth

Ethnicity

Religion Optional

Housing Status

Employment Status

Occupation

Passport Status

UK passport holder Optional

Overseas visitor Optional

EHIC

Holds European Health Insurance Card

Does not have EHIC

Armed Forces

Military veteran Optional

Member of military family Optional

Armed Forces reservist Optional

Left military services Optional

Address Before Enlisting

Street Address Optional Address Line 2 Optional City Optional Postcode Optional

Service Number Optional

Enlistment Date

Day Optional

Month Optional

Year Optional

Discharge Date

Day Optional

Month Optional

Year Optional

Communication Needs

Spoken Language

Interpreter needed

Yes

Other Needs Optional

Carer Details

Are you a carer?

Yes

Cares for Optional

Do you have a carer?

Yes

If you have a carer, do they consent for their details to be held on your medical record?

Yes they consent Optional

No they decline Optional

Carer Name

First Optional Last Optional

Carer Contact Number Optional

Key Code (if needed) Optional

Family History

Do you have a family history of the following conditions – please tick all that apply:

Asthma Optional

Stroke Optional

COPD Optional

Cardiovascular disease Optional

Diabetes Optional

Deep Vein Thrombosis Optional

Hypertension Optional

Cancer Optional

State Relationship to family member for each condition

Allergies

Do you have any allergies?

Yes

List all allergies

Medications

Are you currently on any medication?

Yes

List current medications

If you need your doctor to dispense medicines, please tick the applicable boxes below

I live more than 1.6 km in a straight line from the nearest chemist Optional

I would have serious difficulty in getting them from a chemist Optional

Alcohol Status

What is your weekly alcohol consumption Optional

How often do you have a drink containing alcohol

When drinking, how many units of alcohol do you drink on a typical day

How often have you had 6 + units (if female) or 8 + units (if male) on a single occasion in the last year

Smoking Status

What is your smoking status?

Never smoked tobacco

Ex-cigarette smoker

Ex-electronic cigarette smoker

Cigarette smoker

Electronic cigarette smoker

Exposed to tobacco smoke

Other (pipe, cigar)

Date stopped

Day

Month

Year

How many per day?

Does it contain nicotine?

Yes

Where?

At home

Work

School

Please give details

Join the millions of people who have used Smokefree support to help them stop smoking. From email and text, to our free app and lots of other support, you can choose what’s right for you.

For more information visit: www.nhs.uk/smokefree

Height and Weight

Height

(in metres and cm)

Weight

(in kg)

Women Only

Contraception

Uses contraception Optional

Contraception not needed Optional

Name of contraception

Pregnancy

Currently pregnant Optional

Not pregnant Optional

Estimated Delivery Date

Day

Month

Year

Blood & Organ Donations

Blood Donation

I would like to be a blood donor

I am not willing to donate blood

I have previously been a blood donor

I am a regular blood donor

Organ Donation

I would like to be an organ donor

I am not willing to donate my organs

I am on the NHS organ donation register

I wish to donate my body to medical research

Please make sure your family are aware if you wish to be an organ donor. If you do not want to be an organ donor please visit: www.organdonation.nhs.uk/ or call: 0300 123 23 23 to register your decision.

Data Sharing

There is a balance between privacy and good health care. We normally share information with other health care professionals involved in your care such as doctors, nurses, therapists and pharmacists.

Please tick to confirm your preference to the below data sharing options. Please note that the consent obtained within this section can be changed at any time.

Sharing out – do you consent to the health data recorded by Attleborough Surgeries to be shared with any other organisations that may care for you?

Yes

Sharing in – do you consent to the health data recorded by other care services to be viewed by Attleborough Surgeries?

Yes

Core Summary Care Record Preference – do you consent for your ‘core’ SCR to be shared with other organisations that may care for you?

Yes

Additional Summary Care Record Preference – do you consent for your ‘additional’ SCR to be shared with other organisations that may care for you?

Yes

Patient Declaration

I sign to confirm that the information I have provided is correct to the best of my knowledge and I will contact Attleborough Surgery if I am aware of any changes.

Signature

Supplementary Questions – only applicable for 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. Alternatively for more information: www.nhs.uk/nhs-services/visiting-or-moving-to-england/

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.

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

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

c) I do not know my chargeable status Optional

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 the age of 16.

Are you a parent/guardian completing the form on behalf of a child under the age of 16?

Yes Optional

No Optional

Signature Optional

Name

First Optional Last Optional

On Behalf Of Optional

Relationship to Patient Optional

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?

Yes Optional

No Optional

If you have an EHIC issued by the UK, please select ‘No’.

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

Do you have a non-UK EHIC or PRC?

Yes Optional

No Optional

non-uK european health insurance card (ehic)

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

Country Code Optional

Name Optional

Given Names Optional

Date of Birth

Day Optional

Month Optional

Year Optional

Personal Identification Number Optional

Identification Number of the Institution Optional

Identification Number of the Card Optional

Expiry Date

Day Optional

Month Optional

Year Optional

PRC Validity Period – From

Day Optional

Month Optional

Year Optional

PRC Validity Period – To

Day Optional

Month Optional

Year Optional

Do you have an S1?

Yes Optional

No Optional

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.

Please give your S1 form to the practice staff.

How will your EHIC/PRC/S1 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.