Park Medical Centre Registration Form - Bretton Park Healthcare

Title: *

NHS Number:

Surname: *

First Names:

Prev Surname:

Date of Birth: *

Sex:

Male

Female

Ethnicity: *

First Spoken Language: *

Town and Country of Birth *

Address

Postcode

City

Country

Telephone Number: *

Email Address:

Mobile Number:

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

Your previous address in the UK

Postcode

City

Country

Name of doctor while at that address

Address of previous doctor

Postcode

City

Country

If you are from abroad:

Your first address where registered with a GP

Postcode

City

Country

If previously resident in UK, date of leaving

Date you first came to live in the UK

If you are from the Armed Forces:

Address before enlisting

Postcode

City

Country

Service or Personnel number

Enlistment date

Discharge date

If registering a child under 5:

I wish the child above to be registered with the doctor named overleaf for Child Health Surveillance.

Occupation

If you need your doctor to dispense medicines and appliances * :

* Not all doctors are authorised to dispense medicines.

I live more than 1 mile in a straight line from the nearest chemist.

I would have serious difficulty in getting them from the chemist.

NHS Organ Donor registration:

I would like to join the NHS Organ Donor Register as someone whose organs may be used for transplantation after my death.

Please tick as appropriate:

Any part of my body

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.

Emergency Contact

Name:

Relationship:

Contact Number:

Address:

Postcode

City

Country

I have filled in this form on behalf of

New Patient Questionnaire

Have you ever been seen as a patient at this practice before?

Yes

No

Marital Status

Are you happy to receive text messages from the practice

Yes

No

Are you happy to receive test results by SMS?

Yes

No

Do you speak English?

Yes

No

Do you require an interpreter?

Yes

No

Main language spoken

Pharmacy Details

Please tell us which Pharmacy you would like us to send your prescriptions to

Pharmacy Name

Pharmacy Address

City

County

Postcode

Personal Health Details

Are you currently taking any medication?

Yes

No

Please specify what medication you’re currently taking

Please bring a print out of your current medication with you to your new patient health check.

Are you allergic to any drugs?

Yes

No

(E.G. Penicillin, Aspirin etc)

Please specify which drugs you’re allergic to

Are you allergic to anything else?

Yes

No

Please specify what you’re allergic to

Have you suffered from any of the following serious illnesses?

Check as appropriate

Have you suffered from any other serious illnesses not listed above?

Yes

No

Please specify

Has anyone in your immediate family suffered from any of the following serious illnesses?

Have you had any surgical operations?

Yes

No

Please specify

How many pregnancies have you had?

Do you use any contraception?

Yes

No

Please specify which method of contraception you use

Do you have any children that are adopted or fostered?

Yes

No

Have you had a hysterectomy?

Yes

No

Health Promotion

Have you ever smoked?

Yes

No

Do you smoke now?

Yes

No

Tell us about your alcohol intake: (in units: 1 unit = 1 glass of wine, 1/2 pint of beer etc)

Proof of Identity/Address

Do you have proof of identity?

Yes

No

(Passport, Driver’s License, Photo ID)

Do you have proof of address?

Yes

No

(Valid UK driving licence, Utility bill, Council tax bill, Recent credit card or bank statement)

Upload an image of your proof of ID/Proof of AddressFile Upload

Maximum file size: 50MB