New Patient Registration Additional Information

Name as detailed on your main registration application

First

Last Name

Gender

Is your gender the same as the gender you were assigned at birth?

Please give us further details about your gender.

We need this information to ensure that Primary Care Support England can match your correct NHS Number to your current gender.

What is your sexual orientation?

Date of Birth

Address

Postcode

City

Country

Telephone Number

This must be a UK number

Mobile Number

This must be a UK number

Email

Please provide an email address as we aim to increasingly use this to communicate with patients.

Confirm Email

Are you happy for us to contact you by text message?

Yes

No

Are you happy for us to contact you by letter?

Yes

No

Are you happy for us to contact you by email?

Yes

No

Online Access

Please note: Online access is provided via our clinical system provider (SystmOnline), which requires mandatory proof of ID. (Photo ID can be passport, biometric ID card or driving licence with photo.)

Would you like to be able to book appointments, order repeat prescriptions, etc. online?

Yes

No

NOTE: please ensure you provide proof of ID (1 photo ID).

Please upload your photo ID.

Maximum file size: 268.44MB

Nominated Person

Would you like anyone else to book appointments, pick up prescriptions for you, etc.?

Yes

No

If you answered yes, please fill in the following:

Name

First Name

Last Name

Relationship to Patient

UK Phone Number

Which of the following would you like them to do for you?

Book appointments

Request prescriptions

Pick up prescriptions

Speak to the practice on your behalf

Have full access to your medical records

Please select all that apply.

Blood Pressure

Pulse

Are you able to administer your own medication?

Yes

No

If no, please give details. e.g. swallowing or opening containers

Children Under 7 Years

Are you completing this form for a child aged 7 or under?

Yes

No

Please provide the date that these vaccines were given

These vaccines are usually given at 8 weeks old.

IMMUNISATION HISTORY

This section MUST be completed from your child’s Red Book or other immunisation records.

Diphtheria, tetanus, pertussis (whooping cough), polio, Haemophilus influenzae type b (Hib) and hepatitis B, Vaccine Name: DTaP/IPV/Hib/HepB, Trade Name: Infarix Hexa

Meningococcal group B (MenB), Vaccine Name: MenB, Trade Name: Bexsero

Rotavirus gastroenteritis, Vaccine Name: Rotavirus, Trade Name: Rotarix

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Please provide the date that these vaccines were given

These vaccines are usually given at 12 weeks old.

Diphtheria, tetanus, pertussis, polio, Hib and hepatitis B, Vaccine Name: DTaP/IPV/Hib/HepB, Trade Name: Infarix Hexa

Pneumococcal (13 serotypes), Vaccine Name: Pneumococcal conjugate vaccination (PCV), Trade Name: Prevenar 13

Rotavirus, Vaccine Name: Rotavirus, Trade Name: Rotarix

Add Remove

Please provide the date that these vaccines were given

These vaccines are usually given at 16 weeks old.

Diphtheria, tetanus, pertussis, polio, Hib and hepatitis B, Vaccine Name: DTaP/IPV/Hib/HepB, Trade Name: Infarix Hexa

MenB, Vaccine Name: MenB, Trade Name: Bexsero

Add Remove

Please provide the date that these vaccines were given

These vaccines are usually given at 1 year old (on or after the child’s first birthday)

Hib and MenC, Vaccine Name: Hib/MenC, Trade Name: Mentorix

Pneumococcal, Vaccine Name: PCV Booster, Trade Name: Prevenar 13

Measles, mumps and rubella (German measles), Vaccine Name: MMR, Trade Name: MMR VaxPRO2 or Priorix

MenB, Vaccine Name: MenB Booster, Trade Name: Bexsero

Add Remove

Please provide the date that these vaccines were given

These vaccines are usually given at 3 years and 4 months old or soon after

Diphtheria, tetanus, pertussis and polio, Vaccine Name: DTaP/IPV, Trade Name: Repevax or Boostrix-IPV

Measles, mumps and rubella, Vaccine Name: MMR (check first dose given), Trade Name: MMR VaxPRO2 or Priorix

Add Remove

Please list any OTHER vaccinations that your child has had and the dates, for example BCG, Hepatitis B etc.

If you are female

National Cervical Screening Programme- https://www.nhs.uk/conditions/cervical-screening/

Have you ever had a smear/cytology/PAP test?

Yes

No

Date of last test

Location of last test

NHS GP

Abroad

Privately

If abroad or private, you will need to be tested 1 year from date of last test – book an appointment with nurse.

Results of last test

Normal

Abnormal

Unknown

Please provide details of the result – type of abnormality, any treatment you received, where this was treated and when your next test is due. If you do not have this information or are unsure please make an appointment for a repeat test.

Do you wish to be included in the national cervical cytology programme?

Yes

No

If NO you will be asked to sign a separate disclaimer to exclude you from the program. You can opt back in at any time by simply booking an appointment for cytology screening.

Previous Medical History

Do you or have ever suffered from any the following conditions? Please select all that apply and ensure that you provide the details in the free text box below.

Please provide details of your condition, when and where you were diagnosed and any other relevant information.

Family History

Please give details of any inherited conditions within your family, for example any of those conditions listed above. Please put as much information as possible including which member of your family, what their condition is and approximate age at diagnosis.

Diet and Exercise

How much exercise do you do?

Sedentary (no exercise)

Gentle (climb stairs, walking, gardening)

Moderate (cycling, swimming regularly)

Vigorous (attend gym regularly)

What type of diet do you have?

Are you currently

Homeless

Refugee

An Asylum Seeker

None of the above

Are you housebound

Yes

No

Could you please share the reasons why you are housebound?

Sharing your medical information

Health professionals are trained to keep your records secure and to manage them responsibly and in confidence.

Your GP can now see your medical record held in other organisations that provide your care e.g. your Hospital or Community Clinics. Health professionals e.g. your hospital doctor, district nurse, or physiotherapist treating you can also see your full GP record if you give your permission when they see you.

Sharing your records benefits you because:
• You won’t need to repeat your medical history.
• You may avoid unnecessary appointments and tests.
• Your health professional has the right information at the right time.

Please Note: Some information (without your personal details) may be shared anonymously with health and social care organisations to plan local services and improve public health for everyone.

Can we share your full medical record with other organisations providing you with care?

YES, I am happy for the GP practice to share my full medical record with other organisations providing my care (who will ask my permission to see it)

No, do not share my medical records with other organisations. Please Note: this will mean that we could not share your medical records to hospitals or community clinics when we are referring you for care. Also emergency departments may not have access to your important medical information when treating you.

Are you sure you DO NOT want us to share your information?

Yes, I confirm that I do not want to share my record

No, I confirm I am happy for my record to be shared with my permission

Are you sure you do not want your GP to be able to share your relevant medical record with other organisations that are involved in providing your care e.g. your Hospital or Community Clinics? Health professionals e.g. your hospital doctor, district nurse or physiotherapist treating you. Please be assured information relating to your medical record will only be shared with your permission.

Can we see records held about you by other organisations providing you with care?

YES, I am happy for the GP practice to see records held about me by other organisations providing my care

NO, I do not want the GP practice to see records held about me by other organisations. Please Note: Other organisations include hospitals, other doctors, the nurses and clinics that you may have been referred to. It is important that your GP has access to this information to continue caring for you safely. Selecting “No” could mean that your doctor may not have access to any records relating to your care in the hospital or the community despite being involved in your on-going care

Are you sure you DO NOT want us to recieve information from other healthcare providers who you have seen?

Yes, I confirm that I do not want to share my record

No, I confirm I am happy for my record to be shared with my permission

Are you sure you do not want your GP to be able to share your relevant medical record with other organisations that are involved in providing your care e.g. your Hospital or Community Clinics? Health professionals e.g. your hospital doctor, district nurse or physiotherapist treating you. Please be assured information relating to your medical record will only be shared with your permission. NOTE: If you do not allow sharing of your medical record, this could mean that your doctor may not have access to any records relating to your care in the hospital or the community despite being involved in your on-going care.

To complete your application for registration, where possible, please provide proof of address which is less than 3 months old.

Upload Photo ID (e.g. passport/photo driving licence)

Proof of Address – please attach one document from the list below. This must be less than 3 months old.
• Tenancy agreement
• Mortgage agreement
• Bank statement
• Utilities bill/Council tax statement
• HMRC correspondence

Proof of Address

Maximum file size: 268.44MB