Personal Details Title Date of Birth Gender
For over 16’s it is very helpful for us to see documentation that confirms your ID and address. Please upload 1 piece of photo ID and 1 document that confirms your address. (suitable documents would include passport, driving Licence*, residence permit, travel document, HC2 card, utility bill). *Note – a driving license by itself is adequate as it contains both address and photo ID.
Upload proof of Address Optional Ethnicity Please Select White – British White – Irish White – Turkish White – Greek White – Kurdish White – Other Asian – Indian British Indian Asian – Pakistani British Pakistani Asian Bangladeshi Asian – Other Black – Caribbean Black – African Black – Other Mixed – British Mixed Caribbean Mixed – African Mixed – White & Asian Mixed – Other Ethnic – Chinese Ethnic – Filipino Ethnic – Vietnamese Ethic – Other I do not wish to disclose Address
Email Please help us trace your previous medical records by providing the following information: Your previous address in the UK
Address of previous doctor
Please enter N/A if this does not apply to you. If you are from abroad Your first UK address where registered with a GP
If previously resident in UK, date of leaving Date you first came to live in the UK Supplementary Questions Are you ordinarily a resident in the UK? European Economic Area (EEA) Country 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? Demographics Marital Status Which of the following options best describes you? Sex and gender identity – Which one of the following best describes how you think of yourself? Is your gender identity the same as the gender you were given at birth? Please specify the ethnic group you consider you belong to What is your main religion? Communication Needs Do you speak English? Do you read English? Are you a British Sign Language user? Disability Do you have an impairment, health condition or learning difference that has a substantial or long term (over a year) impact on your ability to carry out day to day activities? (Tick all that apply)
No known impairment, health condition or learning difference
A long standing illness/health condition such as cancer, HIV, diabetes, chronic heart disease, asthma, or epilepsy
A mental health impairment, such as depression, schizophrenia or anxiety disorder
A physical impairment or mobility issues, such as difficulty using your arms or using a wheelchair or crutches
A learning difficulty
Neuro-diverse e.g. dyslexic, dyspraxic or AD(H)D
Deaf or hearing impaired
Blind or have a visual impairment uncorrected by glasses
An impairment, health condition or learning difference that is not listed above
Prefer not to say
Optional Do you have any specific information or communication needs? If so, please specify how we can meet these for you (e.g. large print, Braille, easy read communications) Optional Armed Forces Have you served in the UK Armed Forces and/or been registered with a Ministry of Defence GP in the UK or overseas? Do you have access to secure housing? What is your current immigration status? Carers Do you have caring responsibilities? Do you have a carer? Emergency Contact Are they your next of kin? Do you give us permission to discuss your medical records with them? About You Smoking Status Are you interested in advice on how to quit? Please state how much exercise and what type of exercise you do per week Optional Alcohol Consumption This is one unit of alcohol:
Half pint of regular Beer/Lager/Cider
1 small glass of wine
1 single measure of spirits
1 single measure of aperitifs
1 small glass of sherry
Each of these is more than one unit:
Pint of regular Beer/Lager/Cider (2 Units)
Pint of Premium Beer/Lager/Cider (3 Units)
Alcopop or can/bottle of regular Lager (1.5 Units)
Can of Premium Lager/Strong Beer (2 Units)
Can of super strength lager (4 Units)
Glass of wine (2 Units)
Bottle of wine (9 Units)
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? Do you have any significant family history we should be aware of? Optional Medical History Major Illnesses Optional Please include dates Past Operations Optional Please include dates Family History Illnesses Optional Please include dates Current Medication Optional We routinely offer HIV screening would you be interested in being screened? Sight Hearing Are you over 75 years old?
The Department of Health has advised that all patients of 75 years 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.
Allergies Do you have any allergies? Please specify what you are allergic to, what happens and when you had your first reaction Immunisation History Please list any immunisations/vaccinations you have had Optional Please include dates Important Registration Information
For anyone aged 16 and over, we offer online services for appointment booking and repeat prescription ordering. This is the quickest and easiest way to order your medication. Once registered, you will also be able to view your summary record, detailing current medication, allergies and vaccinations.
You will soon receive an email from the practice with your log in details.
These are confidential: It is your responsibility to ensure they can be received securely by email.
Prescriptions are sent electronically to your nominated pharmacy. We will automatically nominate the pharmacy closest to your post code as part of your registration. If you prefer to use a different chemist please contact the practice to sign up for the Electronic Prescribing Service
Summary Care Record
This record will contain summary 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 with 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 away from home, healthcare staff treating you will have immediate access to important information about your health.
Do you consent to having a Summary Care Record? Your Medical Information – Sharing Your Data
Under the General Data Protection Regulations (GDPR), we have a responsibility to keep your medical records confidential. We need your consent to share this with other authorised health professionals involved in your care or in planning your care. You can find more information on the website at
Please see the privacy notice on our website for more information on how your data is held and used by the practice.
The NHS wants to make sure you and your family has the best care now and in the future. Your health and adult social care information supports your individual care. It also helps us to research, plan and improve health and care services in England.
There are very strict rules on how this data can and cannot be used, and you have clear data rights. We are committed to keeping patient information safe and will always be clear on how it is used.
You can choose whether or not your confidential patient information is used for research and planning.
If you do not wish your information to be used in this way please opt-out by visiting
NHS: Your Data Matters or by calling 0300 303 5678. The practice is unable to record this for you. NHS Organ Donor registration 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 on:
www.blood.co.uk 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.
Signature Declaration Date