Register with a GP Practice - Hereford Road Surgery

Application to Register Permanently with a General Medical Practice

This form must be completed as fully as possible.

1. Personal Details

Title

Date of birth

When you register, it's essential to include your NHS number so that we can register you. You can use the NHS website to find your NHS number

NHS Number

You are:

Male

Female

Surname

Forenames

Known name

Previous surname

Mother's maiden name

Town and country of birth

Address

Postcode

Phone number

2. Information to Help Trace Your Previous GP Health Records

Your previous address in the UK, whilst registered with a GP surgery

Postcode

Name of previous doctor while at that address

Address of previous doctor

3. If you are from abroad

Your first UK address where registered with a GP

If previously resident in the UK, date of leaving

Date you first came to live in the UK

Have you ever registered with a NHS GP in the UK?

Yes

4. If you have served in HM Armed Forces

Have you ever served in HM Armed Forces?

Yes

Enlistment date

Leaving date

Address before enlisting

Service or Personnel number, BFPO Number

5. Checks

If you need your doctor to dispense medicines and appliances (note: 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 a chemist

NHS Individual Health Record Opt Out

I want to opt out of the Individual Health Record and prevent emergency care medical staff being able to access my key medical information. I have received enough information to make an informed decision and I acknowledge that opting out could be detrimental to my healthcare.
Further information is available by visiting www.wales.nhs.uk/individualhealthrecord or by calling NHS Direct on 0845 46 47

Correspondence

Please tick this box if you wish to receive correspondence from us in Welsh

6. Signature

If you need to clear your signature from the box above and start it again, click here.

Your Signature

The above signature is:

The patient's own signature
On behalf of the patient

New Patient Registration/Health Questionnaire

All information supplied will be recorded in your confidential medical records.

Contact Details

Title

Gender

Surname

Forename(s)

NHS number (if known)

Date of birth

Marital status

Ethnicity

Address

Postcode

Home phone number

Work phone number

Mobile number (if aged 16 or over)

Language preference

English
Welsh
Other

If Other, please specify

Do you consent to the practice contacting you by text message for appointment reminders, invitations to health checks, vaccinations reminders and anything else relevant to your healthcare?

Yes

We have an electronic method of contact available for patients to contact the surgery for non urgent requests - do you consent for us to correspond with you via this method and supply us with a preferred email address for this purpose?

Yes

Email address

Smoking

Do you smoke?

Yes
No
Ex-smoker

If Yes, how many cigarettes per day?

...or ounces of tobacco per day?

If ex-smoker, what date did you stop smoking?

Alcohol

For the following questions please answer to the best of your knowledge.

We have provided a basic guide to alcohol content below to assist your completion.

A 750ml bottle of wine contains 10 units.

A standard(175ml) glass of wine contains 2 units.

A single small shot of spirits (25ml) contains 1 unit.

A standard 70cl bottle of spirits contains 28 units.

A pint of 3.6% strength lager/beer/cider contains 2 units.

A pint of 5.2% strength lager/beer/cider contains 3 units.

How many units of alcohol do you drink a week?

Height & Weight

Please tell us your most recent measurements for the following (if known).

Height

Weight

Please note, we may contact you to offer you support or advice if appropriate based on your submission.

Next of Kin

Name

Relation

Contact number

Family History

NB: The following information you supply may assist us to provide good care for you whilst we wait for your previous medical records.

Is there any of the following in your family (father, mother, brother, sister) under the age of 65 with the following illnesses?

Heart Disease?

Yes

If Yes, which family member?

Stroke?

Yes

If Yes, which family member?

Cancer?

Yes

If Yes, which family member?

Site of cancer?

Medication

Please give details of any medication which you take (prescribed or otherwise). Please enter each drug on a separate line.

Name of drug - Dosage

Please add a photo of your most recent repeat medication slip if you have one.

Allergies

Do you have any allergies?

Yes

If Yes, please give details

Past Medical History

Please give details of any treatments/medical conditions.

Carer Information

Do you need / have anyone who looks after you or your daily needs as a Carer?

Yes

If Yes, would you like them to deal with your health affairs here?

Yes

Do you care for anyone else?

Yes

History

Have you been registered here previously?

Yes

Have you moved to the UK from abroad?

Yes

Special Circumstances

Military Veteran

Have you ever served in the Armed Forces?

Yes

Communication

Do you have any communication / information needs relating to sensory loss and, if so, what are they and how would you like us to communicate with you?