2024 Whaddon Healthcare New Patient Registration Form

ANY SECTION UNFILLED MAY RESULT IN LATE REGISTRATION OR YOUR REGISTRATION MAY BE REJECTED. IF YOU ARE UNABLE TO FILL IN THIS ONLINE FORM OR SUBMIT MANDATORY INFORMATION, PLEASE ATTEND THE SURGERY IN PERSON AND COLLECT A PAPER REGISTRATION FORM.

Last Updated: 06/03/2024

ZERO TOLERANCE SCHEME

If you have previously been de-registered under our zero-tolerance scheme you must not register with our practice without first writing to the Practice Manager with your request. If the practice declines your request to register, they will inform you in writing of the decision. The practice has a right to remove your registration at their discretion at any time if you have previously been removed from our list for abusive behavior and not informed them at the point of re-registering.

Patient's Details

Title *

ETHNICITY *

What is your first spoken language? *

DO YOU REQUIRE AN INTERPRETER? *

Yes No

Surname *

First name(s) *

Previous Surname *

Birth Town *

Birth Country *

Date of Birth *

NHS number *

Sex *

Male

Female

Prefer not to disclose

Other

Current/New Address *

Postcode *

What was your previous address and postcode? *

Telephone *

Email Address *

I am a student at: *

If you have come from abroad (or Scotland/Ireland/Wales), please enter your date of entry to the UK

If you have left and returned to England from Abroad (or Scotland/Ireland/Wales) please confirm the dates you left and returned

NEXT OF KIN

NEXT OF KIN NAME *

NEXT OF KIN ADDRESS *

NEXT OF KIN CONTACT NUMBER *

YOUR RELATIONSHIP *

PATIENTS WHO ARE UNDER 16 YEARS OLD

Is this registration for a patient under the age of 16 years? *

Yes No

Parent/Guardians Name: *

Parent/Guardians Date of Birth: *

Parent/Guardians Address: *

Parent/Guardians Contact Number: *

Parent/Guardian Email Address: *

CARE HOME RESIDENTS

ARE YOU A CARE HOME RESIDENT? IF YES, PLEASE SUPPLY FULL CARE HOME ADDRESS *

COMMUNICATION

Do you consent to us contacting you by SMS messages? *

Yes No

Do you consent to us contacting you by email? *

Yes No

How would you prefer us to communicate with you? *

LETTER

TEXT MESSAGE

Is there any other communication support we should provide for you? If yes, please provide details *

Do you lip-read or use a hearing aid or other communication tool? If yes, please advise which? *

Do you need a British Sign Language interpreter or advocate with longer appointment times? If yes, please advise which? *

Do you need information in another format? For example, large print or easy to read? If yes, please advise which? *

ONLINE SERVICES

We do recommend patients sign up for online services.

We request that patients provide identification when registering at the practice. If you’re unable to provide identification, we can still register you, however you won’t be able to access our online services without proof of identification.

Please provide photographic identification and proof of address to register with our online services.

I wish to have access to the following online services (please select all that apply): *

Booking appointments

Requesting repeat prescriptions

Accessing your medical record

PRESCRIPTIONS

Please provide the name & address of your preferred Pharmacy for prescriptions: *

SUMMARY CARE RECORD AND ACCESS

Your Summary Care Record is a short summary of your GP medical records. It tells other health and care staff who care for you about the medicines you take and your allergies. It means they can give you better care if you need health care away from your usual doctor's surgery: for example, in an emergency, when you're on holiday, when your surgery is closed, at out-patient clinics or when you visit a pharmacy.

Your records will automatically be coded for an Enhanced Summary Care record. Please confirm if you are ok to opt in or out *

OPT IN

OPT OUT

THIRD PARTY ACCESS - In the Practice we aim to provide you with the highest quality of healthcare. To do this we must keep records about you, your health, and the care we have provided or plan to provide to you. Everyone working for the NHS has a legal duty to keep information about you confidential. If you would like a family member or carer to have access to your medical records on your behalf. We need to keep their contact details on your records. The person you nominate must be happy to have their details recorded in your medical records. If you wish to nominate someone for this reason, please provide us with their details and CONFIRM below that you consent to this. *

MEDICAL HISTORY

FAMILY HISTORY

PLEASE PROVIDE DETAILS OF YOUR FAMILY HISTORY HEART PROBLEMS, STROKE, CANCER, DIABETES OR ASTHMA., Please specify age and relationship *

MEDICATION

If you are taking regular medication from your previous GP, you will need to book an appointment before our GP’s can issue this, please allow yourself plenty of time so you do not run out of medication and bring along any previous prescription requests / medication with you to the appointment.

Please note we do not accept prescription requests over the phone

PLEASE LIST ANY OVER THE COUNTER MEDICATION USED REGULARLY *

ARE YOU ON WARFARIN OR ON ANY OTHER ANTI-COAGULANT MEDICATION? Please specify below: *

PLEASE ADVISE OF ANY KNOWN ALLERGIES *

LEARNING DISABILITY

Are you under the Learning Disability Team? *

Yes No

If yes, please provide details: *

Do you have a Key Worker? *

Yes No

If yes, please provide details: *

VETERANS

Are you or have you served for the Armed Forces? *

Yes No

iF yES, What is your service number? *

CARERS

Are you a carer for someone else? *

Yes No

Is there someone you rely on for your care? *

Yes No

Would you like to be referred to Carers MK? *

Yes No

HOMELESS

If you are homeless or at risk of homelessness, please complete the information below. The reason we ask for this information is so that we can send a referral to the local homelessness team.

Please be aware once the referral has been sent, the practice will be unable to provide you with further information regarding the referral. The homelessness team will contact you directly

Are you homeless? *

Yes No

Do you give your consent for a referral to MK homelessness team *

Yes No

Are you threatened homelessness? *

Yes No

What date do you expect to become homeless? *

SOCIAL SERVICES

Do you have a social worker? *

Yes No

If yes, please state any information you feel to be appropriate: *

EDUCATION

Are you or is your child currently in education? *

Yes No

Is your child home-schooled? *

Yes No

Which school do you or your child attend? *

PATIENT HEALTH

DO YOU HAVE ANNUAL FLU VACCINATIONS? *

Yes No

HIV

HIV (Human Immunodeficiency Virus) is a virus which attacks the immune system - the body's defence against diseases. That is why it is so important to get tested and know your status, as with early diagnosis, free and effective treatment, most people with HIV will not develop any AIDS related illnesses and are likely to live a normal lifespan.

I would like to be booked an appointment for a new patient health which will include the option of a HIV test *

Yes No

SMEAR TEST ELIGIBILITY

Can you SPECIFY if there is a medical reason for you not to have a smear test? i.e. no cervix, radiotherapy etc. *

ALCOHOL

SMOKING CESSATION

Do you smoke? *

NEVER

EX-SMOKER

YES

iF YES, When did you start smoking? *

How many do you smoke a day? *

Do any of the following apply? (Please circle)

Pipe

Roll ups

Vaping

Cannabis

Would you like help to stop smoking? *

Yes No

CONSENT

I consent to the practice contacting me by text message and/or email message for the purposes of health promotion and for appointment reminders. I acknowledge that appointment reminders by text and/or email are an additional service and that these may not take place on all/or on any occasion and that the responsibility of attending appointments or cancelling them still rests with me. I can cancel the text and/or email message facility at any time. Text messages are generated using a secure facility however I understand that they are sent over a public network onto a personal telephone and as such may not be secure, however the practice will not transmit any information which would enable an individual patient to be identified. I agree to advise the practice if my email address changes and if my mobile telephone number changes or if this is no longer in my possession. The practice does not share mobile phone contact details or email addresses. with any external non-NHS organisation. Your medical records may be used for financial or clinical audit, post payment verification checks, medical research, or education purposes. *

Yes I consent

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2024 Whaddon Healthcare New Patient Registration Form

ANY SECTION UNFILLED MAY RESULT IN LATE REGISTRATION OR YOUR REGISTRATION MAY BE REJECTED. IF YOU ARE UNABLE TO FILL IN THIS ONLINE FORM OR SUBMIT MANDATORY INFORMATION, PLEASE ATTEND THE SURGERY IN PERSON AND COLLECT A PAPER REGISTRATION FORM.

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