New Patient Registration Form – Additional Information New Patient Registration Form – Additional Information Note: This form is strictly private and confidential. All questions must be answered to complete your registration application. Name First Last Gender Male Female Non Binary Date of Birth DD slash MM slash YYYY Are you completing this form for a child aged 7 or under? Yes No Address Street Address Address Line 2 City County Post Code Email Do you wish to receive SMS messages and Reminders? Yes No NOTE: If you select yes, a UK mobile number must be provided.PhoneWould you like to be able to book appointments, order repeat prescriptions, etc. online? Yes No NOTE: please ensure you provide proof of ID (1 photo ID).FileMax. file size: 50 MB.Please upload your photo ID.Would you like anyone else to book appointments, pick up prescriptions for you, etc.? Yes No If you answered yes, please fill in the following:Name First Last Relationship to PatientUK Phone NumberWhich of the following would you like them to do for you? Book appointments Request prescriptions Pick up prescriptions Speak to the practice on your behalf Have full access to your medical records Please select all that apply.Blood PressurePulseAre you able to administer your own medication? Yes No If no, please give details. e.g. swallowing or opening containersChildren Under 7 Years IMMUNISATION HISTORY This section MUST be completed from your child’s Red Book or other immunisation records.Please provide the date that these vaccines were givenDiphtheria, tetanus, pertussis (whooping cough), polio, Haemophilus influenzae type b (Hib) and hepatitis B, Vaccine Name: DTaP/IPV/Hib/HepB, Trade Name: Infarix HexaMeningococcal group B (MenB), Vaccine Name: MenB, Trade Name: BexseroRotavirus gastroenteritis, Vaccine Name: Rotavirus, Trade Name: RotarixThese vaccines are usually given at 8 weeks old.Please provide the date that these vaccines were givenDiphtheria, tetanus, pertussis, polio, Hib and hepatitis B, Vaccine Name: DTaP/IPV/Hib/HepB, Trade Name: Infarix HexaPneumococcal (13 serotypes), Vaccine Name: Pneumococcal conjugate vaccination (PCV), Trade Name: Prevenar 13Rotavirus, Vaccine Name: Rotavirus, Trade Name: RotarixThese vaccines are usually given at 12 weeks old.Please provide the date that these vaccines were givenDiphtheria, tetanus, pertussis, polio, Hib and hepatitis B, Vaccine Name: DTaP/IPV/Hib/HepB, Trade Name: Infarix HexaMenB, Vaccine Name: MenB, Trade Name: BexseroThese vaccines are usually given at 16 weeks old.Please provide the date that these vaccines were givenHib and MenC, Vaccine Name: Hib/MenC, Trade Name: MentorixPneumococcal, Vaccine Name: PCV Booster, Trade Name: Prevenar 13Measles, mumps and rubella (German measles), Vaccine Name: MMR, Trade Name: MMR VaxPRO2 or PriorixMenB, Vaccine Name: MenB Booster, Trade Name: BexseroThese vaccines are usually given at 1 year old (on or after the child’s first birthday)Please provide the date that these vaccines were givenDiphtheria, tetanus, pertussis and polio, Vaccine Name: DTaP/IPV, Trade Name: Repevax or Boostrix-IPVMeasles, mumps and rubella, Vaccine Name: MMR (check first dose given), Trade Name: MMR VaxPRO2 or PriorixThese vaccines are usually given at 3 years and 4 months old or soon afterPlease list any OTHER vaccinations that your child has had and the dates, for example BCG, Hepatitis B etc.Cervical CytologyHave you ever had a smear/cytology/PAP test? Yes Optional No Optional Date of last test DD slash MM slash YYYY Location of last test NHS GP Abroad Privately If abroad or private, you will need to be tested 1 year from date of last test – book an appointment with nurse.Results of last test Normal Abnormal Unknown Please provide details of the result – type of abnormality, any treatment you received, where this was treated and when your next test is due. If you do not have this information or are unsure please make an appointment for a repeat test.Do you wish to be included in the national cervical cytology programme? Yes No If NO you will be asked to sign a separate disclaimer to exclude you from the program. You can opt back in at any time by simply booking an appointment for cytology screening.Previous Medical HistoryDo you or have ever suffered from any the following conditions? Please select all that aply Cancer within the last 5 years COPD Tuberculosis (TB) Heart Attack Epilepsy None of the above If you have ticked any of the above conditions, please make appointment with the Health Care Assistant. Family HistoryPlease give details of any inherited conditions within your family, for example any of those conditions listed above. Please put as much information as possible including which member of your family, what their condition is and approximate age at diagnosis. OptionalDiet and ExcerciseHow much exercise do you do? Sedentary (no exercise) Gentle (climb stairs, walking, gardening) Moderate (cycling, swimming regularly) Vigorous (attend gym regularly) What type of diet do you have? Healthy Moderate Unhealthy Vegan Vegetarian Are you currently Homeless Refugee An Asylum Seeker None of the above Are you housebound Yes No Comments OptionalSharing your medical information Health professionals are trained to keep your records secure and to manage them responsibly and in confidence. Your GP can now see your medical record held in other organisations that provide your care e.g. your Hospital or Community Clinics. Health professionals e.g. your hospital doctor, district nurse, or physiotherapist treating you can also see your full GP record if you give your permission when they see you. Sharing your records benefits you because: • You won’t need to repeat your medical history. • You may avoid unnecessary appointments and tests. • Your health professional has the right information at the right time. Please Note: Some information (without your personal details) may be shared anonymously with health and social care organisations to plan local services and improve public health for everyone.Can we share your full medical record with other organisations providing you with care? YES, I am happy for the GP practice to share my full medical record with other organisations providing my care (who will ask my permission to see it) No, do not share my medical records with other organisations. Please Note: this will mean that we could not share your medical records to hospitals or community clinics when we are referring you for care. Also emergency departments may not have access to your important medical information when treating you. Can we see records held about you by other organisations providing you with care? YES, I am happy for the GP practice to see records held about me by other organisations providing my care NO, I do not want the GP practice to see records held about me by other organisations. Please Note: Other organisations include hospitals, other doctors, the nurses and clinics that you may have been referred to. It is important that your GP has access to this information to continue caring for you safely. Selecting “No” could mean that your doctor may not have access to any records relating to your care in the hospital or the community despite being involved in your on-going care To complete your application for registration, where possible, please provide photographic ID and proof of address which is less than 3 months old. Upload Photo ID (e.g. passport/photo driving licence) Proof of Address – please attach one document from the list below. This must be less than 3 months old. • Tenancy agreement • Mortgage agreement • Bank statement • Utilities bill/Council tax statement • HMRC correspondencePhoto IDMax. file size: 50 MB.Proof of AddressMax. file size: 50 MB.Post Custom Field Optional