New patient registration form – The Willow Tree Surgery

Patient's details

Title(Required)

First names(Required)

Surname(Required)

Date of birth(Required)

Do you know the NHS number of the person you are registering?(Required)

Yes

NHS Number(Required)

Previous surnames(Required)

Please enter N/A if not applicable

Sex(Required)

Male

Female

Town and country of birth(Required)

Home address(Required)

Postcode(Required)

Telephone number(Required)

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

Your previous address in UK(Required)

Please enter N/A if not applicable

Name of previous GP practice while at that address(Required)

Please enter N/A if not applicable

Address of previous GP practice while at that address(Required)

Please enter N/A if not applicable

If you are from abroad

Your first UK address where registered with a GP(Required)

Please enter N/A if not applicable

If previously resident in UK, date of leaving(Required)

Please enter N/A if not applicable

Date you first came to live in the United Kingdom(Required)

Please enter N/A if not applicable

Were you ever registered with an Armed Forces GP

Please indicate if you have served in the UK Armed Forces and/or been registered with a Ministry of Defence GP in the UK or overseas(Required)

Address before enlisting(Required)

Please enter N/A if not applicable

Service or Personnel number(Required)

Please enter N/A if not applicable

Postcode(Required)

Please enter N/A if not applicable

Enlistment date

Discharge date (if applicable)

Footnote: These questions are optional and your answers will not affect your entitlement to register or receive services from the NHS but may improve access to some NHS priority and service charities services.

I want to register my details on the NHS Organ Donor Register as someone whose organs/tissue may be used for transplantation after my death. Please tick the boxes that apply.

Please tell your family you want 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.

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.

Yes I would like to join the NHS Blood Donor Register

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

My preferred address for donation is: (only if different from above, e.g. your place of work)

All blood types are needed, especially O negative and B negative. Visit www.blood.co.uk or call 0300 123 23 23.

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

Complete this section if you live in another EEA country, or have moved to the UK to study or retire, or if you live in the UK but work in another EEA state. Do not complete this section if you have an EHIC card issued by the UK.

Do you have a non-UK EHIC or PRC?(Required)

If you select yes please complete the additional details from your EHIC card that will appear below.

Yes

Country code(Required)

Name(Required)

Given names(Required)

Date of birth(Required)

Personal Identification Number(Required)

Identification number of the institution(Required)

Identification number of the card(Required)

Expiry date(Required)

PRC validity period (a) From:(Required)

PRC validity period (b) To:(Required)

S1 form

Please tick this box if you have an S1 (eg 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 practice staff.

Yes I have an S1 form

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.

More about who you are registering

Who is being registered?(Required)

Please choose the correct age band so we can show you the correct questions below.

Adult over 16 years

Child from 13 to 16 years

Child from 1 to 12 years

Newborn up to 1 year

Adult's mobile number(Required)

This is the Adult's mobile phone number. If the child is over 13 please provide the mobile number for the responsible adult here and the child's mobile in the box below (it is only visible if the correct age is selected above).

Child's mobile number(Required)

Home telephone(Required)

Please enter N/A if not applicable

Email(Required)

Enter Email Confirm Email

Occupation/Job (current/past)(Required)

Please enter N/A if not applicable

Are you retired?(Required)

Yes

Are you homeless?(Required)

Yes

If you are homeless, may we use the address you registered with for confidential post?(Required)

Yes

Next of kin

Next of Kin full name(Required)

Relationship to you(Required)

Please enter N/A if not applicable

Next of Kin contact number(Required)

Do they have any formal power of attorney for medical care? (if so, please attach the certificates below)(Required)

Note, we will only contact this person in case of emergencies, and we will never share confidential information without your consent

Yes

More about a child or newborn

Name of person with parental responsibility(Required)

Relationship to you(Required)

Name of GP surgery at which they are registered(Required)

Their current home address(Required)

Name and address of school/nursery attended(Required)

School/nursery phone number(Required)

Do you require an interpreter?(Required)

We offer double appointments for patients who need a language interpreter or BSL. Please ask at reception when booking an appointment.

Yes

Main language spoken(Required)

Are you a smoker?(Required)

If yes – we offer smoking cessation services at the practice. Please tick if you would like more information about this.

Yes

Never smoked

Ex-Smoker

How many per day?(Required)

Please send me smoking cessation services information(Required)

Yes

When did you quit?(Required)

Do you drink alcohol?(Required)

Yes

If yes, how many units per week?(Required)

How often do you physically exercise?(Required)

Daily

Weekly

Occasional

What is your height?(Required)

What is your weight?(Required)

Do you have any allergies? YES (please specify)(Required)

Yes (please specify below)

Allergy details(Required)

Are you currently receiving care elsewhere?

Yes

Please provide further information(Required)

Please list below your current repeat medication(Required)

Pharmacy choice(Required)

We are a paper-free surgery, as such our prescriptions are all sent electronically to a pharmacy of your choice. Please let us know which pharmacy you would like prescriptions to be sent to (this can be changed at a future date).

Do you currently have or had any of the following?(Required)

Family history

Are you adopted?(Required)

Yes

Does anyone in your family have or previously had any of the following(Required)

Females only

Please let us know the date of your last cervical screening (smear) test

(if you are over 25 years old)

Have you had any children?(Required)

Yes

Please give the dates of birth of your children(Required)

Have you had a hysterectomy?(Required)

Yes

Please give the date of the hysterectomy(Required)

Do you have a coil or implant?(Required)

Yes

Please give the date when fitted(Required)

Carer information

A carer is a person who looks after a relative, friend, or a child with a physical or learning disability (this may include a mental health problem, long-term illness, or frailty). This definition does not include those who are paid carers.

Are you a carer or a young carer?(Required)

Yes

Do you have a carer yourself?(Required)

Yes

If yes, please give your carer’s name and emergency contact details below(Required)

Do you have a social worker?(Required)

Yes

If yes, please provide the name and contact details(Required)

Looked after child/Child in care

A child who has been in the care of their local authority for more than 24 hours is known as a looked after child/child in care.

Are you a looked after child?(Required)

Yes

Who are you living with?(Required)

I am living with foster parents

I am living in a residential children's home

I am living in residential settings (e.g. school or secure unit)

If yes, please provide the name and contact details(Required)

Protected characteristics (Equality Act 2010)

All the information given on this form will be kept in the strictest confidence, as part of your medical records.

Please only complete those sections you feel confident in completing or you feel are appropriate for the age of the patient. Please note that this information is helpful to our clinicians to allow them to provide you with the best quality and individualised service that we can offer.

At birth were you described as (please tick one option)

Male

Female

Intersex

Prefer not to say

Which of the following describes how you think of yourself? (please tick one option)

If you choose Other, please describe how you think of yourself in another way.

Male

Female

Other

Have you gone through any part of a process (including thoughts or actions) to change from the sex you were described as at birth to the gender you identify with, or do you intend to? (This could include changing your name, wearing different clothes taking hormones or having any gender reassignment surgery).

Yes

Continuing to think about these examples, which of the following options best applies to you? Please tick one option

I am thinking about going through this process

I am currently going through this process

I have already been through this process

I have been through this process, then changed back

None of the above

I prefer not to say

Which of the following describes how you think of yourself? (tick all that apply)

I think of myself in another way as described here

Ethnicity

What is your ethnic group?

Choose one option that best describes your ethnic group or background

I describe my ethnicity as

What is your religion/belief

Disability

You're disabled under the Equality Act 2010 if you have a physical or mental impairment that has a 'substantial' and 'long-term' negative effect on your ability to do normal daily activities.

Do you have a disability?(Required)

Yes

Do you need information communicated to you in a specific format?(Required)

Yes

Do you need support when attending the surgery?(Required)

Yes

If yes, please describe any special help you require: (e.g. unable to manage stairs, easy-read information, sight/hearing assistance)

Sexual orientation

PPG

Our Patient Participation Group (PPG) is chaired by patients and provides the practice with feedback on how we improve our service delivery to meet the needs of our patients. We are an enthusiastic group and are always looking for new members to contribute.

Please tick here if you would like to be added to our PPG mailing list, to receive news and invitations to PPG meetings

Yes please

New borns and under 5 immunisations

For new-born babies and children aged under 5 years, we require an up-to-date immunisation history. If you do not have this information please tick here(Required)

I do not have this information

Would you like to register for online services?(Required)

You can book/cancel appointments, order prescriptions and see your read coded record and results online

Yes

Do you consent to receiving SMS messages?(Required)

This is only via email and we send about five emails per year.

Yes

Students only

Students are at risk of certain infections including mumps, meningitis and sexually transmitted infections, as well as mental health issues including stress, anxiety and depression. Please see www.nhs.uk/Livewell/Studenthealth

I am less than 24 years old and have had two doses of the MMR Vaccination

Yes

Unsure

I am less than 25 years old and have had a Meningitis C Vaccination

Yes

Unsure

NHS patient information sharing - my choices

This section of the form covers the Summary Care Record and the Enhanced Data Sharing Model 'SystmOne'. If you would like to know more about these things, please see the following links. NHS Health Records - Enhanced Data Sharing Model

Please complete and/or tick the boxes below to detail your personal decisions regarding the 2 aspects of NHS patient data sharing. It is very important you sign this form to say that you understand and accept the risks to your personal health care if you do decide to opt out of SCR or EDSM. You will need to do this when you next visit the surgery.

1. SCR - NHS SUMMARY CARE RECORD(Required)

Is a summary of a patient's sensitivities/allergies/current medication, which is uploaded to the national Spine. It can be accessed by any legitimate Clinician and is beneficial when a patient is seen at a hospital /Out of Hours/temporary resident at a GP practice. It is advisable to stay registered for this service.

Express consent for medication, allergies and adverse reactions only

Express consent for medication, allergies, adverse reactions and additional information

Express dissent – Patient does not want a summary care record and fully understands the risks involved with this decision

EDSM – ENHANCED DATA SHARING MODEL "SystmOne" Sharing Out – Do you consent to the sharing of data recorded by your GP practice with other NHS organisations that may care for you?(Required)

YES share data with other NHS organisations

NO do NOT share any data recorded by my GP Practice; I fully accept the risks associated with this decision

Sharing In – Do you consent to your GP Practice viewing data that is recorded at other NHS organisations and care services that may care for you?(Required)

Consent Given

Consent Refused; I fully accept the risks associated with this decision.

Signature

You will be asked to sign this form when you visit the practice and provide ID and proof of address. If you were born outside of the UK, bring your Passport and Visa with you.

Please enter your full name below

Today's date

Comments

This field is for validation purposes and should be left unchanged.