New Patient Registration Form - Dolphin House Surgery

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Title

Mrs

Miss

Other

NHS Number:

Surname:

First Names:

Prev Surname: Optional

Date of Birth

Day

Month

Year

Sex:

Male

Female

Ethnicity:

First Spoken Language:

Town and Country of Birth:

Address

Street Address Address Line 2 City Post code

Telephone Number

Mobile Number

Email Address

Enter Email Confirm Email

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

If you are already registered with a surgery in the Ware area, please advise the reason as to why you are looking to transfer surgeries so that we can manage expectations. If you have moved from outside of the area, please mark N/A in this box.

Previous Address

Street Address Optional Address Line 2 Optional City Optional Post Code Optional

Name of Doctor while at that address

Address of previous doctor

Street Address Address Line 2 City Post code

Please provide the name of the pharmacy that you would like your prescriptions to go to Optional

Are you from abroad?

Yes

Are you in the Armed Forces?

Yes

If you are from abroad:

Your first address where registered with a GP

Street Address Optional Address Line 2 Optional City Optional ZIP / Postal Code Optional Country Optional

If previously resident in UK, date of leaving Optional

DD slash MM slash YYYY

Date you first came to live in the UK Optional

DD slash MM slash YYYY

If you are from the Armed Forces:

Address before enlisting

Street Address Optional Address Line 2 Optional City Optional ZIP / Postal Code Optional Country Optional

Service or Personnel number Optional

Enlistment date Optional

DD slash MM slash YYYY

Discharge date Optional

DD slash MM slash YYYY

If registering a child under 5:

I wish the child above to be registered with the doctor named overleaf for Child Health Surveillance. Optional

If you need your doctor to dispense medicines and appliances:

Not all doctors are authorised to dispense medicines.

I live more than 1 mile in a straight line from the nearest chemist. Optional

I would have serious difficulty in getting them from the chemist. Optional

NHS Organ Donor registration:

To become a Doner, please register directly with NHS Organ Donation on https://www.organdonation.nhs.uk

Please tick as appropriate:

Any part of my body Optional

Or only my:

Kidneys Optional

Heart Optional

Liver Optional

Corneas Optional

Lungs Optional

Pancreas Optional

NHS Blood Donor registration

I would like to join the NHS Blood Donor Register as someone who may be contacted and would be prepared to donate blood. I understand that I will need to register this directly with NHS Organ Donation via https://www.organdonation.nhs.uk Optional

Tick here if you have given blood in the last 3 years. Optional

Next of Kin

Name:

Relationship: Optional

Contact Number:

Address

Street Address Address Line 2 City Post Code

I have filled in this form on behalf of

NEW PATIENT QUESTIONNAIRE

Please answer these questions to the best of your ability and hand this questionnaire into the receptionist. The information will be used to update your personal medical record.

Name

Date Of Birth

Day

Month

Year

Phone Number

Email Address

Height

Weight

What is your smoking status?

How many cigarettes do you smoke a day?

When did you stop smoking?

DD slash MM slash YYYY

Do you drink Alcohol?

How many units a week do you drink?

How often do you have a drink containing Alcohol?

How many drinks containing alcohol do you drink on a typical day?

1 drink = 1/2 pint of beer or 1 glass of wine or 1 single spirits.

How often in the last year have you had 6 or more units (Female) or 8 or more units (Male) on a single occasion?

Do you have any allergies?

Which Drugs/Medication? Optional

What are your allergies?

Are you on any regular medication?

What medication?

Have you recently come to the U.K. from a country which has a high incidence of tuberculosis e.g. Lithuania or Romania?

If you have had a cough or any unexplained weight loss recently please make an appointment to see one of the doctors.

From which Country? Optional

Are you a student?

Have you had your MeningitusACWY vaccination?

Section Break

SUMMARY CARE RECORD – your emergency care summary

NHS England has introduced the Summary Care Record, which will be used in emergency care. The record will contain information about any medicines you are taking, allergies you suffer from and any bad reactions to medicines you have had to ensure those caring for you have enough information to treat you safely. Your Summary Care Record will be available to authorised healthcare staff providing you care anywhere in England, but they will ask your permission before they look at it. This means that if you have an accident or become ill, healthcare staff treating you will have immediate access to important information about your health.

GP practices are supporting Summary Care Records and as a patient you have a choice:

For more information talk to the Patient Advice and Liaison Service (PALS), GP practice staff, visit the website www.nhscarerecords.nhs.uk or telephone the dedicated NHS Summary Care Record Information Line on 0300 123 3020. You can choose not to have a Summary Care Record and you can change your mind at any time by informing your GP practice. If you do nothing we will assume that you are happy with these changes and create a Summary Care Record for you. Children under 16 will automatically have a Summary Care Record created for them unless their parent or guardian chooses to opt them out. If you are the parent or guardian of a child under 16 and feel that they are old enough to understand, then you should make this information available to them.

The Department of Health has asked us to record the ethnic origin, and first language, of all new patients. Please tick the box which most accurately describes you:

White – British

White – Irish

Other White background

White/Black Caribbean

White/Black African

White/Asian

Other mixed background

Chinese

Indian/British Indian

Pakistan/British Pakistan

Bangladesh/British Bangladesh

Other Asian background

Caribbean/British Caribbean

African/British African

Other Black background

Other ethnic background

Prefer not to say

What is your first main spoken language?

Will you need a translator when you see one of our medical team?

THANK YOU FOR TAKING THE TIME TO COMPLETE THIS QUESTIONNAIRE

Untitled Optional