Fill this form if you are 14 years of age and over.

Personal Details
Surname Title
Forename(s) Gender
Previous Surname Date of Birth
Town of Birth NHS No:
Your Current Address and Contact Information
House name or No Phone
Street Mobile
Location

Do you wish to receive Appointment reminders by text to
Town

your mobile phone?

County

Post Code  
Your Previous UK Address and GP
Help us trace your medical records by providing details of your previous UK address and doctor.
Previous Address
Street        
Town         
County   
Post Code



Name and Address of previous GP
GP Name
Surgery
Address


If you are from abroad
Your first UK address where registered with a GP
If previously resident in UK, Date of leaving
Date you first came to live in UK    
If you are returning from the Armed Forces
Address before enlisting
Service or Personnel number Enlistment date                   
If you need your Doctor to dispense medicines and appliances
I live more than 1 mile in a straight line from the nearest chemist
I would have serious difficulty in getting them from a chemist
Not all doctors are authorised to dispense medicines
NHS Organ Donor registration
I want to register my details on the NHS Organ Donor Register as someone whose organs/tissue may be used for transplantation after my death. Please tick the boxes that apply.
Any Organ   Kidneys   Heart   Liver   Corneas   Lungs   Pancreas
 For more information, please ask at reception for information leaflet or visit the website www.uktransplant.org.uk or call 0845 60 60 400
NHS Blood Donor registration
I would like to join the NHS Blood Donor Register as someone who may be contacted and would be prepared to donate blood.
Tick here if you have given blood in the last 3 years
For more information, please ask for the leaflet on joining the NHS Blood Donor Register.
My preferred address for donation is: (only if different from above, e.g. your work place)
Next of Kin
Name
Address
Phone
Relationship
Ethnicity
We are required to record information regarding your ethnic origin. Please tick the appropriate box (you may refuse this information if you wish).
White British or Mixed British
Irish
Other White Background
Mixed White and Black Caribbean
White and Black African
White and Asian
Other Mixed Background
Asian or
Asian British		 Indian or British Indian
Pakistani or British Pakistani
Bangladeshi or British Bangladeshi
Other Asian Background
Black or
Black British		 Caribbean
African
Other Black Background
Other Ethnic Group Chinese
Other
Not Stated or
Patient Refused		 Ethnic Category not stated
Patient Refused
New Patient Questionnaire (aged 14 and over)
Please complete the details below so we know as much about you as possible.
Height      Weight
Have any of your relatives suffered from:

Please state affected relative       

Diabetes
A heart attack
Angina
A stroke
Raised blood pressure                
Breast cancer specify age
Have you had Rheumatic Fever?
Do you need antibiotic cover for dental treatment?
Do you have inherited condition? If so, what condition
What serious illnesses have you had? (please give year)
What operations have you had? (please give year)
Are you allergic to any drugs or dressings? If so, please specify
What regular medication are you taking? (Include contraceptive pills or injections and all regular herbal or over the counter remedies)
Do you have any speech or hearing impediment? If so, please specify
Occupation Number of children
If you are 75 or over, do you live alone?  
Do you smoke? If so, how much?  
Have you ever smoked? Date you stopped
How much alcohol do you drink per week?
What recreational exercise do you take each week?
When were you last immunised against: Tetanus Polio
Have you been immunised against:
Hepatitis A Hepatitis B Typhoid Pneumococcus Flu
Are you a Carer of a relative / friend / neighbour?
Alcohol
How often do you have a drink that contains alcohol?  
How many standard alcoholic drinks (units) do you have on a typical day when you are drinking?
How often do you have 6 or more standard drinks on one occasion?
Women Only
Have you had any miscarriages or any other complication in pregnancy? If so, when?
Have you ever had a cervical smear? If so, when?
Have you ever had a screening test for breast cancer? If so, when?
I confirm that the Information I have given is correct. By submitting this form I agree that I will be registered with my new practice as soon as possible on or after the date below without further confirmation. I understand that by registering with this practice my registration with my current doctor will be ended and my records transferred.
I also confirm that I have read the Welcome and Life Style advice letter      
I want to be registered from this date:

You may be asked to provide evidence of entitlement to NHS care.
Accepted documents are:
European Health Insurance Card (EHIC)
Passport (including Visa for stay in the UK)
NHS Medical Card
Photo Driving Licence
Birth Certificate
Marriage Certificate
National Insurance Number Card
Evidence of benefit entitlement
Wage slip with employer's details