The Arch Medical New Patient Registration – OneContact Patient Portal

Your Details

Title

First Names

Surname

Previous Surname

Date of Birth

NHS Number

Please type “unknown” if you do not know this.

Gender

Male

Female

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

Yes

No

Would you describe yourself as intersex?

Yes

No

Intersex is a general term used for a variety of situations in which a person is born with reproductive or sexual anatomy that doesn’t fit the boxes of “female” or “male.”

What is your sexual orientation?

Marital status

Religion

Please Specify other religion:

Town of birth

Country of Birth

Date Of Entry To The UK

Current Manchester Address

Postcode

Do you give us permission to communicate with you by text?

Yes

No

UK Mobile Number

Do you give us permission to communicate with you by email?

Yes

No

Email

Please ensure that your email address is correct.

Home Telephone

Work Telephone

How would you prefer us to contact you?

Mail

Text

Email

Work

Are you or the person you are registering aged 18 or under?

Yes

No

Is the patient currently in education?

Yes

No

Name of Nursery/School/College/University

Is the patient known to a health visitor?

Yes

No

Name of Health Visitor

Contact number of Health Visitor

Is the patient known to Social Services?

Yes

No

Name of Social Worker

Have you previously been registered with a GP in the UK?

Yes

No

Are you a main carer (unpaid) for someone who has poor health or disability?

Yes

No

Are you currently a University student?

Yes

No

Are you an international student?

Yes

No

Which university?

Course Start Date

Course End Date

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

Name of previous doctor

Address of previous doctor

What was your address when you were registered with your previous doctor?

If you are from abroad

Date you first came to live in UK

Date you plan on leaving the UK (if applicable)

Ethnicity

Ethnic Group

Please Specify

What is your main spoken language?

Do you need an interpreter (someone to help with language) when you visit the doctor?

Yes

No

What is your main reading language?

for example; English/French/Spanish etc..

Do you have any problems reading English?

I have no problems

I have some problems

I have a lot of problems

Do you have any problems speaking English?

I have no problems

I have some problems

I have a lot of problems

Height and Weight

Weight

Unit of measurement *

Height

cm

Weight

kg

Height

ft

Inches

in

Weight

lbs

BMI

Underweight

Healthy

Overweight

Obese

Emergency Contact – Next of Kin

Full Name

Contact Number

Relationship to you

Address

Carer Information

Are you a Carer?

Yes

No

Who do you care for?

Do you have a Carer?

Yes

No

Please provide details of your Carer:

Armed Forces

Are you returning from the armed forces?

Yes

No

Address before enlisting

Service or personnel number

Enlistment Date

NHS Organ and Blood Donor registration

If you would like to join the NHS Organ and blood Donor register visit: www.organdonation.nhs.uk or call 0300 123 2323

Women Only

Have you ever received a cervical (pap) smear test?

Yes

No

Don’t know

Date of last smear

Are you currently pregnant?

Yes

No

Due Date

Medical History

Please list any important illnesses

Please list any medication you are currently taking

Please note: If you are taking any medication, you will need to see a Doctor before you request a repeat prescription.

Do you have any of the allergies listed below?

Penicillin Allergy

Yes

No

Nut Allergy

Yes

No

Egg Allergy

Yes

No

Latex Allergy

Yes

No

Reaction to ibuprofen

Yes

No

Reaction to paracetamol

Yes

No

Hay Fever

Yes

No

Reaction to Amoxicillin

Yes

No

Reaction to Ceporex

Yes

No

Allergy to Animal

Yes

No

Please list any OTHER allergies that are not listed above

Lifestyle

Do you smoke?

Yes

No

Ex-smoker

Cigarettes per day

Date you quit

Would you like help to stop smoking?

Yes

No

Do you drink Alcohol?

Yes

No

How often do you have a drink containing alcohol?

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

How often have you had 6 or more units if female, or 8 if male, on a single occasion in the last year?

European Economic Area (EEA) Country

For a list of EEA countries Click Here

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?

Yes

No

Do you have a non-UK European Health Insurance Card (EHIC) or a Provisional Replacement Certificate (PRC)?

Yes

No

If you are visiting from another EEA country and do not hold a current EHIC (or Provisional Replacement Certificate (PRC))/S1, you may be billed for the cost of any treatment received outside of the GP practice, including at a hospital.

EHIC/PRC

Please enter the details from your EHIC or PRC below.

Country Code

Name

Given Names

Date of Birth

Personal Identification Number

Identification number of the institution

Identification number of the card

Expiry Date

Validity period – from:

Validity period – to:

Patient Records

Summary Care Records Consent preference

Express Consent

Express Dissent (OPT-OUT) – I do not want a summary care record

Summary Care Records (SCR) are an electronic record of important patient information,created from GP medical records. They can be seen and used by authorised staff in other areas of the health and care system involved in the patient’s direct care.

Type 1 opt-out: medical records held at your GP practice – Dissent from Secondary Use of GP Patient Identifiable Data Form

I dissent from secondary use of GP patient identifiable data

Previously you could tell your GP practice if you did not want us, NHS Digital, to share confidential patient information that we collect from across the health and care service for purposes other than your individual care. This was called a type 2 opt-out.

The type 2 opt-out was replaced by the national data opt-out. Type 2 opt-outs recorded on or before 11 October 2018 have been automatically converted to national data opt-outs.

Signed

I declare that the information I give on this form is correct and complete. I understand that if it is not correct, appropriate action may be taken against me.

A parent/guardian should complete the form on behalf of a child under 16

Signature

Clear

Print name

Date

On behalf of:

Relationship to patient