New patient registration

Patient’s Details

Please specify:

Surname:

Previous Surnames:

First Name(s)

Sex

Male

Female

Indeterminate

NHS Number:

How to find your NHS Number

Town and Country of birth:

Home Address:

Postcode:

Home Phone Number:

Mobile Phone Number:

Work Phone Number:

Can we contact you by text?

Yes

No

Can we contact you by email?

Yes

No

Preferred method of contact:

SMS

Letter

Occupation:

Nominated pharmacy:

Information or communication needs:

Please detail any specific needs you have so that the practice can ensure they are identified and accommodated by taking the appropriate action.

Ethnicity

Please state:

Do you speak English?

Yes

No

Do you read English?

Yes

No

First Language:

Lifestyle

Height:

Weight:

Smoking Status:

Current Smoker

Ex Smoker

Never Smoked

Are you interested in advice on how to quit?

Yes

No

How many did you smoke per day?

When did you stop?

Please state how much exercise and what type of exercise you do per week:

Alcohol Consumption

This is one unit of alcohol:

And each one of these, is more than one unit:

How often do you have a drink containing alcohol?

How many units of alcohol do you drink on a typical day when you are drinking?

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?

Emergency Contact/Next of Kin

Full Name:

Relationship to you:

Phone Number:

Are they your next of kin?

Yes

No

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

Yes

No

Application for online access to my medical record

I wish to have access to the following online services:

Please select all that apply

I wish to access my medical record online and understand and agree with each statement:

I have read and understood the information leaflet provided by the practice

I will be responsible for the security of the information that I see or download

If I choose to share my information with anyone else, this is at my own risk

I will contact the practice as soon as possible if I suspect that my account has been accessed by someone without my agreement

If I see information in my record that is not about me or is inaccurate, I will contact the practice as soon as possible

Signature:

Full name

Date:

Carers

Do you have a carer?

Yes

No

Are you a carer for someone?

Yes

No

Name of carer: