Online Registration Form Personal DetailsFirst NameSurnamePrevious Surname OptionalAddress Street Address Address Line 2 City Postcode Main Contact NumberAlternative Contact Number OptionalEmail Enter Email Optional Confirm Email Optional NHS NumberDate of Birth Day Month Year Town of BirthCountry of BirthEthnicityPlease SelectWhite – BritishWhite – IrishWhite – TurkishWhite – GreekWhite – KurdishWhite – OtherAsian – IndianBritish IndianAsian – PakistaniBritish PakistaniAsian BangladeshiAsian – OtherBlack – CaribbeanBlack – AfricanBlack – OtherMixed – BritishMixed CaribbeanMixed – AfricanMixed – White & AsianMixed – OtherEthnic – ChineseEthnic – FilipinoEthnic – VietnameseEthic – OtherI do not wish to discloseGender (at birth) Female Male Which of the following gender identities best describes how you think of yourself?Please selectMale (inc. trans men)Female (inc. trans women)Non-binaryIn another wayPrefer not to sayPlease help us trace your previous medical records by providing the following information:Are you from abroad? Yes No Your previous address in the UK Street Address Address Line 2 City Postcode Name of doctor while at that address OptionalAddress of previous doctor Street Address Address Line 2 City Postcode Your first UK address where registered with a GP Street Address Address Line 2 City Postcode 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 Immigration StatusWhat is your current immigration status? Yes No Please present your ARC card or a letter from the Home Office at the surgery.Max. file size: 50 MB.Armed ForcesAre you, or have you ever served in the UK Armed Forces? Yes No What was your enlistment date? Day Month Year If applicable, what was your discharge date? Day Optional Month Optional Year Optional Communication NeedsDo you speak English? Yes No What is your main spoken language?Do you require an interpreter? Yes No Are you a British Sign Language user? Yes No CarersAre you a carer? Yes No Do you have a carer? Yes No Carer's Name First Last Carer's Contact NumberDo you give us permission to discuss your medical records and appointments with your carer? Yes No Next of Kin DetailsFull Name First Last Relationship to youContact NumberDo you give us permission to discuss your medical records and appointments with your next of kin? Yes No Medical History and Lifestyle QuestionsAre you currently taking any medication? Yes No Please list any medication you are currently taking.Who is your nominated pharmacy for electronic prescribing?Please describe your eyesight: Good Poor Registered Blind Please describe your hearing: Good Poor Partially Deaf Deaf Do you have any allergies? Yes No Please specifyDo you use a wheelchair to mobilise? Yes No Are you housebound? Yes No Have you ever been diagnosed with cancer? Yes No Please indicate your diagnosis, with dates if possible. OptionalDo you have a learning difficulty? Yes No Please indicate your diagnosis with dates if possible. OptionalHave you had any serious Illnesses? Yes No Please indicate your diagnosis with dates if possible. OptionalHave you had any major operations? Yes No Please list these with dates if possible. OptionalDo you have a family history of any illnesses? Yes No Please list these with dates if possible. OptionalDo you have an impairment, health condition or learning difference that is not listed above? Yes No Please indicate your diagnosis, with dates if possible. OptionalHeight(cm)Weight(kg) Alcohol Consumption This is one unit of alcohol: • Half pint of regular Beer/Lager/Cider • 1 small glass of wine • single measure of spirits • 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)Think about your regular drinking habits; do you consider yourself to be a:Please selectLifetime non-drinker of alcoholTrivial drinker (less than 1 unit of alcohol per day)Light drinker (1-2 units of alcohol per day)Moderate Drinker (3-6 units of alcohol per day)Heavy Drinker (7-9 units of alcohol per day)Very heavy drinker (more than 9 units of alcohol per day)Ex DrinkerIf you feel like you need advice or support regarding your alcohol intake, call DRINKLINE on 0300 123 1110 for free confidential advice or visit www.nhs.uk/live-well/alcohol-advice/alcohol-support. You can also visit/contact the surgery for advice.What is your smoking Status?Please selectCurrent SmokerEx SmokerNever SmokedUser of a vapee-CigaretteIf you are a current smoker’, how many cigarettes do you smoke per day?If you roll your own cigarettes, how many grams of tobacco do you smoke per week? OptionalFor help with stopping smoking, call the SMOKEFREE NATIONAL HELPINE on 0300 123 1044 or visit www.nhs.uk/better-health/quit-smoking/find-your-local-stop-smoking-service/. You can also visit/contact the surgery for advice. Contact PreferencesThe practice will contact you via telephone and by post where required.Do you also consent to being contacted by text message? Yes No Do you also consent to being contacted by email? Yes No Online AccessFor 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 book appointments and view your medical record. If you wish to register, please give your consent below; you will 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.Do you consent to online access being set up on registration by the practice? Yes No Please confirm your email address Enter Email Confirm Email Summary Care RecordThis 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 No Your Medical Information – Sharing Your DataUnder 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. 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 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 RegistrationFor more information on organ donation please visit www.organdonation.nhs.uk. NHS Blood Donor RegistrationIf you would like to join the NHS Blood Donor Register, please visit www.blood.co.uk or call direct on 0300 123 2323. SignaturePlease upload your two forms of Identification (one photographic and one proof of address) Drop files here or Select files Max. file size: 50 MB, Max. files: 2. Declaration I certify that the information I have provided is correct and consent to my personal and medical information being used as stated above. Your Full NameDate Day Month Year Signature