New Patient Registration (Over 16) - Hounslow and Richmond Template

If you are new to the area and wish to register with the GP surgery, please complete the form below – each person registering will need to complete a form.

Non-urgent advice: Please note

There is a different form for children aged under 16 – New Patient Registration Form (Child: Under 16 years).

Personal Details

Title

Mrs

Miss

Other

NHS Number (if known) Optional

First Names

Surname

Previous Surname Optional

Date of Birth

Day

Month

Year

Gender

Female

Male

Ethnicity

Town* and Country of Birth

*Please include borough if born in London

Address

Street Address Address Line 2 City Postcode

Main Contact Number

Mobile Telephone Number Optional

Home Contact Number Optional

We will use your mobile number to send appointment reminders and health promotion details.

I do not wish to receive these messages Optional

Enter Email Optional Confirm Email Optional

How would you prefer us to contact you?

Letter Optional

Email Optional

SMS (text) Optional

Phone Optional

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

Your previous address in the UK

Street Address Optional Address Line 2 Optional City Optional Postcode Optional

Name of doctor while at that address Optional

Address of previous doctor

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

If you are from abroad

Your first UK address where registered with a GP

Street Address Optional Address Line 2 Optional City Optional Postcode Optional

If previously resident in UK, date of leaving

Day Optional

Month Optional

Year Optional

Date you first came to live in the UK

Day Optional

Month Optional

Year Optional

If this is your first GP registration in the UK, please provide us the name of the country and date of arrival.

Country Name Optional

Date of Arrival Optional

TB test Offered

Yes Optional

No Optional

TB test accepted

Yes Optional

No Optional

Armed Forces

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:

Regular Optional

Reservist Optional

Veteran Optional

Family Member (Spouse, Civil Partner, Service Child) Optional

Address before enlisting: Optional

Service or Personnel number Optional

Enlistment date

Day Optional

Month Optional

Year Optional

Discharge date (if applicable)

Day Optional

Month Optional

Year Optional

Please note that 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 or service charities services.

NHS Charges Regulations 2015 Self Declaration

I am a British Resident and entitled to full NHS Care

Yes Optional

No Optional

I have paid the Immigration Health Surcharge (IHS)

Yes Optional

No Optional

I hold a non-UK issued European Health Insurance Card (EHIC) (Complete details on reverse of GMS1 form)

Yes Optional

No Optional

I hold a S1 form (entitlement to health care in another EEA country for a limited duration)

Yes Optional

No Optional

Demographics

Marital Status

Single, never married

Married

Civil Partnership

Divorced

Widowed

Separated

What is your main religion?

No religion Optional

Christian (including Church of England, Catholic, Protestant, and all other Christian denominations) Optional

Buddhist Optional

Hindu Optional

Jewish Optional

Muslim Optional

Sikh Optional

Other Optional

Do you have access to secure housing?

Yes

What is your current immigration status?

Asylum Seeker Optional

Failed Asylum Seeker Optional

Carers

Do you have caring responsibilities?

None

Primary carer of a child/children (under 18)

Primary carer of disabled child/children

Primary carer of disabled adult (18 and over)

Primary carer of older person

Secondary carer (another person carries out the main caring role)

Prefer not to say

Do you have a carer?

Yes

Carer’s Name

First Last

Relationship to you

Address of carer

Street Address Address Line 2 City Postcode

Telephone number of carer

Next of Kin

Your choice should be someone you feel close to. It does not have to be a blood relative or spouse. Before listing them on any medical documents, you should ask their permission and explain the role.

Full Name

Relationship to you

Contact Number

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

Yes

Communication and Access Needs

Do you speak English?

Yes

Do you read English?

Yes

Are you a British Sign Language user?

Yes

What is your main spoken language?

Do you need an interpreter?

Yes

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 Optional

A long standing illness/health condition such as cancer, HIV, diabetes, chronic heart disease, asthma, or epilepsy Optional

A mental health impairment, such as depression, schizophrenia or anxiety disorder Optional

A physical impairment or mobility issues, such as difficulty using your arms or using a wheelchair or crutches Optional

A learning difficulty Optional

Neuro-diverse e.g. dyslexia, dyspraxia or AD(H)D Optional

Deaf or hearing impaired Optional

Blind or have a visual impairment uncorrected by glasses Optional

An impairment, health condition or learning difference that is not listed above Optional

Prefer not to say Optional

Do you have any specific mobility, information or communication needs? If so, please specify how we can meet these for you (e.g. large print, Braille, easy read communications) Optional

Please state

Are you an ‘Assistance Dog’ User?

Yes Optional

No Optional

Are you housebound?

Yes Optional

No Optional

Health Information

Height

(in centimetres)

Weight

(in kilograms)

Smoking Status

Current Smoker

Ex Smoker

Never Smoked

How many of the below do you smoke per day?

Cigarettes per day

Cigars per day Optional

Grams of pipe tobacco per day Optional

Are you interested in advice on how to quit?

Yes

How would you describe your diet? Optional

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?

Never

Monthly or less

2-4 times per month

2-3 times per week

4+ times per week

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

1-2

3-4

5-6

7-9

10+

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?

Never

Less than monthly

Monthly

Weekly

Daily or almost daily

Medical History

What operations or serious injuries have you had? Optional

Have you or anyone in your family (brother, sister, parents, grandparents, aunt, uncle) had any of the following?

Cancer Optional

Heart Attack under the age of 60 Optional

Heart disease (under the age of 60) Optional

Heart disease (over the age of 60) Optional

High cholesterol Optional

Stroke Optional

Diabetes Optional

Asthma Optional

Thyroid disorder Optional

COPD Optional

High Blood Pressure Optional

Hypertension Optional

Depression Optional

Bipolar or Schizophrenia Optional

Chronic kidney disease Optional

Emphysema Optional

Other Optional

Please specify

If you answered yes to any of the above, please provide additional information.

Women Only

What is the date and result of your last Smear test?

Date Optional

Result Optional

Was this at:

GP Surgery Optional

Other NHS Optional

Private Optional

Abroad Optional

Date of last Mammogram (if applicable): Optional

Current Medication

Please list any medications or treatments you are undertaking and for what condition. Optional

Are you able to administer your own medicines?

Yes

Please give details, e.g. swallowing or opening containers.

Allergies

Do you have any allergies?

Yes

Please provide more information.

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

Further Information

Do you have a ‘Living Will’ or ‘Advanced Directive’?

Yes Optional

No Optional

An advance decision (sometimes known as an advance decision to refuse treatment, an ADRT, or a living will) is a decision you can make now to refuse a specific type of treatment at some time in the future.

Have you nominated someone who has Power of Attorney or been assigned a Personal Welfare Deputy?

Yes Optional

No Optional

Online Services

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.

I do not want to be registered for online services Optional

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?

Yes

Medical Record Sharing allows your complete GP medical record to be made available to authorised healthcare professionals involved in your care. You will always be asked your permission before anybody looks at your shared medical record.

Do you want to share your GP record?

Yes

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 www.nhs.uk/your-nhs-data-matters.

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

For more information on organ donation please visit: www.organdonation.nhs.uk

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

Signature

Declaration

I certify that the information I have provided is correct and consent to my personal and medical information being used as stated above. Optional

Signature

Your Full Name

Date

Day

Month

Year

Non-urgent advice: Please note

Personal Details

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

If you are from abroad

Armed Forces

NHS Charges Regulations 2015 Self Declaration

Demographics

Carers

Next of Kin

Communication and Access Needs

Disability

Health Information

How many of the below do you smoke per day?

Alcohol Consumption

This is one unit of alcohol:

Each of these is more than one unit:

Medical History

Women Only

What is the date and result of your last Smear test?

Current Medication

Allergies

Immunisation History

Further Information

Online Services

Summary Care Record

Your Medical Information – Sharing Your Data

NHS Organ Donor registration

NHS Blood Donor registration

Signature

Chiswick Primary Care Network

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