New Patient Registration Form 			       Please complete all pages in full using block capitals

1. Background Details	

Contact Details	
NHS Number	NHS Number 	If you have had a previous GP then you will find this on letters/prescriptions or at www.nhs.uk/find-nhs-number	
	 I do not know my NHS number		
Name	Full Name 	Gender	Gender(full) 	
Which of the following best describes how you think of yourself?	 Non-binary       Female         Male          Prefer not to say        Unable to answer	
Is your gender the same as the sex you were assigned at birth?	 Yes           	 Prefer not to say
 No		 Unable to answer	
Previous Surname
(if applicable)	Previous Surname 	
Address	Home Full Address (stacked) 	Date of Birth	Date of Birth 	
		Home Telephone	Patient Home Telephone 	
		Work Telephone	Patient Work Telephone 	
Previous Address	     	
Mobile Telephone	 I consent to be contacted* by SMS on this number: Patient Mobile Telephone 	
Email	 I consent to be contacted* by email at this address: Patient E-mail Address      	
Next of Kin	Name:      	Tel:      	Relationship:      	
Family Registered With Us	     	
Has the patient been registered in the NHS before? 	 Yes 	 No
If no please state date entered UK:      	

 * It is your responsibility to keep us updated with any changes to your telephone number, email & postal address.
   We may contact you with appointment details, test results, health campaigns or Patient Participation Group details
   If you do not consent to being contacted by SMS or Email, please tick here:    SMS    Email

Other Details	
Previous GP	Name:                                             	Address:      	
Country of Birth	Ethnic Origin      	
Ethnicity	 White (UK)
 White (Irish) 
 White (Other) 	 Black Caribbean
 Black African
 Black Other	 Bangladeshi
 Indian 
 Pakistani	 Chinese
 Other	
Religion	 C of E
 Catholic
 Other Christian 	 Buddhist
 Hindu
 Muslim	 Sikh
 Jewish
 Jehovah’s Witness	 No religion
 Other:	
Housing	 Own House
 Rented House
 Shared House	 Nursing Home
 Residential Home
 Sheltered Home	 Homeless 
 Housebound	 Asylum Seeker 
 Refugee	
Employment	 Employed 
 Self-employed	 Student
 Unemployed	 House husband 
 House wife	 Carer
 Retired	
Overseas Visitor	 Yes	 European Health Insurance Card Held (please bring details with you)	
Armed Forces	 Military Veteran	 Family member 			

Communication Needs	
Language	What is your main spoken language?	Main Language      
Do you need an interpreter?              	Interpreter required  	
Communication	Do you have any communication needs?     Yes         No (If Yes please specify below)	
	 Hearing aid
 Lip reading	 Large print
 Braille	 British Sign Language
 Makaton Sign Language     Guide dog	
Learning disability 	Do you have a Learning Disability?                   Yes         No
(If Yes please request a Learning Disability Screening Tool form)	

Carer Details	
Are you a carer?	 Yes – Informal / Unpaid Carer	 Yes – Occupational / Paid Carer	 No	
Do you have a carer?	 Yes    	Name*:      	Tel:      	Relationship:      	
* Only add carer’s details if they give their consent to have these details stored on your medical record

2. Medical History	

Medical History	
Have you suffered from any of the following conditions?	
 Asthma
 COPD
 Epilepsy	 Heart Disease
 Heart Failure
 High Blood Pressure	 Diabetes
 Kidney Disease
 Stroke	 Depression
 Underactive Thyroid
 Cancer- Type:	
Any other conditions, operations or hospital admission details:
See below      

If you are currently under the care of a Hospital or Consultant outside our area, please tell us here:
     	

Family History	
Please record any significant family history of close relatives with medical problems and confirm which relative e.g. mother, father, brother, sister, grandparent	
 Asthma      
 COPD      
 Epilepsy      	 Heart Disease      
 Stroke      
 Blood Pressure      	 Diabetes      
 Kidney Disease      
 Liver Disease      	 Depression      
 Thyroid      
 Cancer      	
Other:
     	

Allergies	
Please record any allergies or sensitivities below
See below      	

Vaccinations	

Has Full Name had all their routine vaccinations? 		 Yes	 No 
 
Did Full Name get all their routine vaccinations in the UK?	 Yes	 No 	

Current Medication	
Please check and include as much information about your current medication below
Please give us your previous repeat medication list if possible and a medication review appointment may be needed
See below      	

3. Your Lifestyle	

Alcohol	
Please answer the following questions which are validated as screening tools for alcohol use:	
AUDIT–C QUESTIONS	Scoring System	Your Score	
	0	1	2	3	4		
How often do you have a drink containing alcohol?	Never	Monthly or Less	2-4 times per month	2-3 times per week	4+ times per week	     	
How many units of alcohol do you drink on a typical day when you are drinking?	1-2	3-4	5-6	7-9	10+	     	
How often have you had 6 or more units if female, or 8 or more if male, on a single occasion in the last year?	Never 	Less than monthly	Monthly	Weekly	Daily or almost daily 	     	

A score of less than 5 indicates lower risk drinking 	TOTAL:	     	
                                    Scores of 5 or more requires the following 7 questions to be completed:	

AUDIT QUESTIONS
(after completing 3 AUDIT-C questions above)	Scoring System	Your Score	
	0	1	2	3	4		
How often during the last year have you found that you were not able to stop drinking once you had started?	Never 	Less than monthly	Monthly	Weekly	Daily or almost daily 	     	
How often during the last year have you failed to do what was normally expected from you because of your drinking?	Never 	Less than monthly	Monthly	Weekly	Daily or almost daily 	     	
How often during the last year have you needed an alcoholic drink in the morning to get yourself going after a heavy drinking session?	Never 	Less than monthly	Monthly	Weekly	Daily or almost daily 	     	
How often during the last year have you had a feeling of guilt or remorse after drinking?	Never 	Less than monthly	Monthly	Weekly	Daily or almost daily 	     	
How often during the last year have you been unable to remember what happened the night before because you had been drinking?	Never 	Less than monthly	Monthly	Weekly	Daily or almost daily 	     	
Have you or somebody else been injured as a result of your drinking?	No		Yes, but not in last year		Yes, during last year	     	
Has a relative or friend, doctor or other health worker been concerned about your drinking or suggested that you cut down?	No		Yes, but not in last year		Yes, during last year	     	
 	TOTAL:	     	

3. Your Lifestyle - Continued	

Smoking	
Do you smoke?	 Never smoked   	 Ex-smoker        	 Yes     	
Do you use an e-Cigarette?	 No                     	 Ex-User            	 Yes     	
How many cigarettes did/do you smoke a day?	 Less than one      	 1-9        10-19  	 20-39     40+	
Would you like help to quit smoking?	 Yes                   	 No		
	For further information, please see: www.nhs.uk/smokefree	
Smoking 

Activity (GPPAQ)	
1.	Please tell us the type and amount of physical activity involved in your work.	Please mark one box only	
A	I am not in employment (e.g. retired, retired for health reasons, unemployed, fulltime carer etc.)		
B	I spend most of my time at work sitting (such as in an office)		
C	I spend most of my time at work standing or walking. However, my work does not require much intense physical effort (e.g. shop assistant, hairdresser, security guard, childminder, etc.)		
D	My work involves definite physical effort including handling of heavy objects and use of tools (e.g. plumber, electrician, carpenter, cleaner, hospital nurse, gardener, postal delivery workers etc.) 		
E	My work involves vigorous physical activity including handling of very heavy objects (e.g. scaffolder, construction worker, refuse collector, etc.)		
2.	During the last week, how many hours did you spend on each of the following activities?	None	Some but less than 1 hour	1 hour but less than 3 hours	3 hours or more	
A	Physical exercise such as swimming, jogging, aerobics, football, tennis, gym workout etc.					
B	Cycling, including cycling to work and during leisure time					
C	Walking, including walking to work, shopping, for pleasure etc.					
D	Housework/Childcare					
E	Gardening/DIY					
3.	How would you describe your usual walking pace?	Please mark one box only	
A	Slow pace (i.e. less than 3 mph)		
B	Steady average pace		
C	Brisk pace		
D	Fast pace (i.e. over 4 mph)		

Height & Weight	
Height 
Height 	
Weight
Weight 	
Waist Circumference 
Single Code Entry: Waist circumference...  	
Blood Pressure (if known)
Blood Pressure 	

Women Only	
Do you use any contraception?
Do you have a coil or implant in situ?	 Yes      No   If needed, please book appointment. 
 Yes      No   Date inserted:      	
Are you currently pregnant or think you may be?	 Yes      No   Expected due date:      	

Students Only	
Students are at risk of certain infections including mumps, meningitis and sexually transmitted infections, as well as mental health issues including stress, anxiety and depression. Please see www.nhs.uk/Livewell/Studenthealth 	
I am less than 24 years old and have had two doses of the MMR Vaccination	 Yes   	 No        	 Unsure    	
I am less than 25 years old and have had a Meningitis C Vaccination	 Yes                   	 No            	 Unsure   	

4. Further Details	

How well do you use a mobile phone or internet to communicate with your GP Practice	
I am able to use Information Technology to communicate with my Practice				
I have difficulty using Information Technology to communicate with my Practice			     	
I am unable to use Information Technology				

Named Accountable GP	
The GP who has overall responsibility for your care is?	Usual GP Full Name 	
You are however entitled to make an appointment to see any GP of your choice, subject to availability.

Electronic Prescribing	
If you would like your prescriptions to be sent electronically, 
please provide details of the pharmacy you would like to use:	Pharmacy:      	

Patient Participation Group	
Would you like to be involved in our Patient Participation Group?	 Yes      No 	
We are committed to improving the services we provide. The Patient Participation Group is a mechanism for us to gain valuable feedback from our patients about their experiences, views and ideas for improving our services.  
Blood and Organ Donation	
Blood Donation	If you are interested in blood donation and would like to register as a blood donor, please visit https://www.blood.co.uk/ 	
Organ Donation	If you are interested in organ donation and would like to register your decision, please visit: https://www.organdonation.nhs.uk/ 	

Signatures	
Signature	     
I confirm that the information I have provided is true to the best of my knowledge.
 Signed on behalf of patient	
Name	Full Name 	
Date	Short date letter merged 	

Checklist
Please ensure the following are done and provided so that your registration can be completed successfully
	Completed & Signed Above Form	
	Completed & Signed GMS1 Form	
	Photo Proof of ID   e.g. Passport, Photo Driving License or Photo ID card	
	Proof of Address    e.g. Bank statement, Utility Bill or Council Tax from within the last 3 months	

Practice Use Only
Appointment	 Required	 Not Required           			
Photo ID	 Passport	 Driving licence           	 Identity card         	 Other      	
Proof of Address	 Utility Bill      	 Council Tax  	 Bank Statement   	 Other      	

5. Sharing Your Health Record	

Your Health Record	
Do you consent to your GP Practice sharing your health record with other organisations who care for you?

     Yes (recommended option)
     No, never

Do you consent to your GP Practice viewing your health record from other organisations that care for you?

     Yes (recommended option)
     No	

Your Summary Care Record (SCR)	

Do you consent to having an Enhanced Summary Care Record with Additional Information?

     Yes (recommended option)
     No	

Signature	
Signature	     	
	 Signed on behalf of patient	
Name	     	
Date	Short date letter merged 	

Problems 

Medication 

Allergies 

Full Name 	Date of Birth 	NHS Number 

Sharing Your Health Record

What is your health record?
Your health record contains all the clinical information about the care you receive.  When you need medical assistance it is essential that clinicians can securely access your health record. This allows them to have the necessary information about your medical background to help them identify the best way to help you. This information may include your medical history, medications and allergies.

Why is sharing important?
Health records about you can be held in various places, including your GP practice and any hospital where you have had treatment. Sharing your health record will ensure you receive the best possible care and treatment wherever you are and whenever you need it. Choosing not to share your health record could have an impact on the future care and treatment you receive. Below are some examples of how sharing your health record can benefit you:

•	Sharing your contact details 	This will ensure you receive any medical appointments without delay
•	Sharing your medical history 	This will ensure emergency services accurately assess you if needed
•	Sharing your medication list	This will ensure that you receive the most appropriate medication
•	Sharing your allergies		This will prevent you being given something to which you are allergic 
•	Sharing your test results 		This will prevent further unnecessary tests being required

Is my health record secure?
Yes. There are safeguards in place to make sure only organisations you have authorised to view your records can do so. You can also request information regarding who has accessed your information from both within and outside of your surgery.

Can I decide who I share my health record with?
Yes. You decide who has access to your health record. For your health record to be shared between organisations that provide care to you, your consent must be gained.

Can I change my mind?
Yes. You can change your mind at any time about sharing your health record, please just let us know.

Can someone else consent on my behalf?
If you do not have capacity to consent and have a Lasting Power of Attorney, they may consent on your behalf. If you do not have a Lasting Power of Attorney, then a decision in best interests can be made by those caring for you.

What about parental responsibility?
If you have parental responsibility and your child is not able to make an informed decision for themselves, then you can make a decision about information sharing on behalf of your child. If your child is competent then this must be their decision.

What is your Summary Care Record?
Your Summary Care Record contains basic information including your contact details, NHS number, medications and allergies. This can be viewed by GP practices, Hospitals and the Emergency Services. If you do not want a Summary Care Record, please ask your GP practice for the appropriate opt out form. With your consent, additional information can be added to create an Enhanced Summary Care Record. This could include your care plans which will help ensure that you receive the appropriate care in the future.

How is my personal information protected?
Organisation Name will always protect your personal information. For further information about this, please see our Privacy Notice on our website or please speak to a member of our team

For further information about your health records, please see: https://www.nhs.uk/using-the-nhs/about-the-nhs/your-health-records/ 
For further information about how the NHS uses your data for research & planning and to opt-out, please see: www.nhs.uk/your-nhs-data-matters

6. Online Access To Your Health Record 	
Name 	Full Name 	
NHS Number	NHS Number 	
Date of Birth	Date of Birth 	
Address	Home Full Address (single line)  	
Telephone	H: Patient Home Telephone M: Patient Mobile Telephone 	
Email Address	Patient E-mail Address      	

I wish to have online access to: Please tick all that apply	
 Book appointments	
 Request medication	
 View my medical record (subject to policy)	
 View my Summary Care Record	
 Complete online questionnaires	

I wish to access my medical record & understand & agree with each statement: Please tick all that apply	
 I have read and understood the ‘Important Information’ section below	
 I will be responsible for the security of the information that I see or download	
 If I choose to share my information with anyone else, this is at my own risk	
 I will contact the practice as soon as possible if I suspect that my account has been accessed by someone without my agreement	
 If I see information in my record that it not about me, or is inaccurate I will log out immediately and contact the practice as soon as possible	

Please bring photographic proof of your identification in order for the sign-up process to be completed

Signature	
Signature	     	
Name	Full Name 	
Date	Short date letter merged 	

For Practice Use Only:
Identity verified through
(tick all that apply)	 Self Vouching
 Vouching with information in record   
 Photo ID
 Proof of residence
 Professional Vouching	
Name of Verifier		Date		
Name of person who authorised and added to SystmOne		Date		
Photocopied this page	 Yes – Name:	
Passed for scanning	 Yes – Name:	

Access to GP Online Services	

Important Information – Please read before completing form below

If you wish to, you can now use the internet (via computer or mobile app) to book appointments with a GP, request repeat prescriptions for any medications you take regularly and look at your medical record online. You can also still use the telephone or call in to the surgery for any of these services as well.  It’s your choice.

It will be your responsibility to keep your login details and password safe and secure.  If you know or suspect that your record has been accessed by someone that you have not agreed should see it, then you should change your password immediately. If you are unable to do this for some reason, we recommend that you contact the practice so that they can remove online access until you are able to reset your password.

If you print out any information from your record, it is also your responsibility to keep this secure.  If you are at all worried about keeping printed copies safe, we recommend that you do not make copies at all. 

During the working day it is sometimes necessary for practice staff to input into your record, for example, to attach a document that has been received, or update your information. Therefore you will notice admin/reception staff names alongside some of your medical information – this is quite normal.  

The definition of a full medical record is all the information that is held in a patient’s record; this includes letters, documents, and any free text which has been added by practice staff, usually the GP. The coded record is all the information that is in the record in coded form, such as diagnoses, signs and symptoms (such as coughing, headache etc.) but excludes letters, documents and free text.

Before you apply for online access to your record, there are some other things to consider. Although the chances of any of these things happening are very small, you will be asked that you have read and understood the following before you are given login details.

Forgotten history 
There may be something you have forgotten about in your record that you might find upsetting. 	
Abnormal results or bad news  
If your GP has given you access to test results or letters, you may see something that you find upsetting to you. This may occur before you have spoken to your doctor or while the surgery is closed and you cannot contact them. 	
Choosing to share your information with someone 
It’s up to you whether or not you share your information with others – perhaps family members or carers. It’s your choice, but also your responsibility to keep the information safe and secure.  	
Coercion 
If you think you may be pressured into revealing details from your patient record to someone else against your will, it is best that you do not register for access at this time.	
Misunderstood information 
Your medical record is designed to be used by clinical professionals to ensure that you receive the best possible care.  Some of the information within your medical record may be highly technical, written by specialists and not easily understood. If you require further clarification, please contact the surgery for a clearer explanation. 	
Information about someone else 
If you spot something in the record that is not about you or notice any other errors, please log out of the system immediately and contact the practice as soon as possible.	

For further information, please see: 
www.nhs.uk/NHSEngland/AboutNHSservices/doctors/Pages/gp-online-services.aspx