New Patient Registration

Patient’s Details

Title
Please use this date format: DD/MM/YYYY.
Sex
Any responses we send will go to this email address.
Can we contact you by text?
Can we contact you by email?
Preferred method of contact:
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 specify the ethnic group you consider you belong to:
Do you speak English?
Do you read English?

Lifestyle

Smoking Status:
Are you interested in advice on how to quit?

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

Are they your next of kin?
Do you give us permission to discuss your medical records with them?

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:
Full name

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?