New Patient Registration Form (ADULTS): The Avenue Medical Centre

Fields marked "REQUIRED" are compulsory.. You should only send this form if you are sure that you are eligible to join this practice. Sending this form will NOT automatically register you with the surgery. Sending this form does NOT guarantee or even imply that you will be accepted onto the practice register.

Last Updated: 20/09/2022

Patients Details (Summary)

Title *

Do you consent to us sending you text messages relating to your care e.g. appointment reminders, communication from the Doctor or results, your annual review?

Yes No

Registration Type, are you registering as a Permanent Patient or just Temporary? *

Permanent Registration

Temporary Registration 3 Months

Temporary Registration 6 Months

Surname *

First name(s) *

Previous Surname

Birth Town *

Birth Country *

Date of Birth *

NHS number

Gender *

Male

Female

Address *

Postcode *

Main Telephone Number *

Additional Telephone Number

Email Address

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

Your previous address in UK (Enter N/A if No Previous Address) *

Name of previous GP while at previous address

Address of that Doctor

If you are from abroad

Your first UK address where registered with a GP (N/A if not applicable) *

If previously resident in UK, date of leaving

Date you first came to live in UK (N/a if not applicable) *

Other

Please indicate if you have served in the UK Armed Forces and/or been registered with a Ministry of Defence GP in the UK or overseas (optional)

Yes No

Do you have access to secure housing? If not, are you? (optional)

What is your current immigration status? (optional)

AsylumSeeker

Failed Asylum Seeker

If you are returning from the armed forces

Address before enlisting

Service/Personnel No.

Enlistment date

Demographics

What is your ethnic group? (Choose one option that best describes your ethnic group or background) (optional) *

What is your main spoken language? (optional) *

What is the main language you read in (example: English, French , Polish)? *

What is your main religion? (optional) *

Sex and Gender identity- which of the following best desrcibes you? *

Is the gender you identify with the same as your sex registered at birth? *

Marital Status *

Carers

Do you have caring responsibilities? (optional)

None

Primary carer of a child/children (under 18)

Primary carer of disabled child/children

Primary carer of disabled adult (18 and over)

Primary carer of older person

Secondary carer (another person carries out the main caring role)

Prefer not to say

Do you have a carer? (optional)

Yes No

If you do have a carer, please provide us with their name and contact details below: (optional)

Please provide us with a name and contact details for your Next of Kin (optional)

Communication Needs

Your Health

Height (optional)

Weight (optional)

Your current smoking status: (optional)

None

I am currently smoking

I used to smoke

I have never smoked

If current smoker, please indicate what you currently smoke and how many per day (optional)

Do you have any significant family history we should be aware of? Please list: (optional)

Alcohol Consumption

Important Registration Information

For anyone aged 16 and over we offer online services for appointment booking and repeat prescription ordering. This is the quickest & easiest way to order your medication. Once registered, you will also be able to view your summary record, detailing current medication, allergies and vaccinations. You will soon receive an email from the practice with your log in details. These are confidential: It is your responsibility to ensure they can be received securely by email.

Prescriptions are sent electronically to your nominated pharmacy. We will automatically nominate the pharmacy closest to your post code as part of your registration. If you prefer to use a different chemist please give the name and address of it below (optional)

Summary Care Record: (www.nhscarerecords.nhs.uk)

This record will contain summary information about any medicines you are taking, allergies you suffer from and any bad reactions to medicines you have had to ensure those caring for you have enough information to treat you safely. Your Summary Care Record will be available to authorised healthcare staff providing you with care anywhere in England, but they will ask your permission before they look at it. This means that if you have an accident or become ill away from home, healthcare staff treating you will have immediate access to important information about your health.

Do you consent to having a Summary Care Record?

Yes No

YOUR MEDICAL INFORMATION – SHARING YOUR DATA:

Under the General Data Protection Regulations (GDPR), we have a responsibility to keep your medical records confidential. We need your consent to share this with other authorised health professionals involved in your care or in planning your care. More information is available on the website or the number below. Please see the Privacy Notice on our website for more information on how your data is held and used by the practice. Your Data Matters: nhs.uk/your-nhs-data-matters Tel: 0300 303 5678 The NHS wants to make sure you and your family has the best care now and in the future. Your health and adult social care information supports your individual care. It also helps us to research, plan and improve health and care services in England. There are very strict rules on how this data can and cannot be used, and you have clear data rights. We are committed to keeping patient information safe and will always be clear on how it is used. You can choose whether or not your confidential patient information is used for research and planning. If you do not wish your information to be used in this way please opt-out by visiting the Website nhs.uk/your-nhs-data-matters or calling 0300 303 5678. The practice is unable to record this for you.

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New Patient Registration Form (ADULTS): The Avenue Medical Centre

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