The Arch Medical New Patient Registration

New Patient Registration

Custom – Arch MC -Patient Reg Form

Your Details

Please type “unknown” if you do not know this.
Is your gender the same as the gender you were assigned at birth?
Would you describe yourself as intersex?
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
Do you give us permission to communicate with you by text?
Do you give us permission to communicate with you by email?
Please ensure that your email address is correct.
How would you prefer us to contact you?
Are you or the person you are registering aged 18 or under?
Is the patient currently in education?
Is the patient known to a health visitor?
Is the patient known to Social Services?
Have you previously been registered with a GP in the UK?
Are you a main carer (unpaid) for someone who has poor health or disability?
Are you currently a University student?
Are you an international student?

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

If you are from abroad


Ethnic Group
Do you need an interpreter (someone to help with language) when you visit the doctor?
for example; English/French/Spanish etc..
Do you have any problems reading English?
Do you have any problems speaking English?

Height and Weight


Unit of measurement *



Emergency Contact – Next of Kin

Carer Information

Are you a Carer?
Do you have a Carer?

Armed Forces

Are you returning from the armed forces?

NHS Organ and Blood Donor registration

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

Women Only

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

Medical History

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
Nut Allergy
Egg Allergy
Latex Allergy
Reaction to ibuprofen
Reaction to paracetamol
Hay Fever
Reaction to Amoxicillin
Reaction to Ceporex
Allergy to Animal


Do you smoke?
Would you like help to stop smoking?
Do you drink Alcohol?
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?
Do you have a non-UK European Health Insurance Card (EHIC) or a Provisional Replacement Certificate (PRC)?
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.


Please enter the details from your EHIC or PRC below.

Patient Records

Summary Care Records Consent preference
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

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.

Read more about the collection and conversion of type 2 opt-outs.


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