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New patient registration

New Patient Registration – The Gill Medical Centre

Patient’s Details

Title:
Please use this date format: DD/MM/YYYY
Sex:
Are you currently pregnant?
Are you under the age of 16?
Please specify the ethnic group you consider you belong to:
Do you require an interpreter?
Are you a military veteran?
Were you ever registered with an armed forces GP?
Do you consider yourself to have a disability?
Do you consent to receiving text messages?
Do you consent to receiving emails?
Do you have any dependents?
Have you been registered as a patient here before?
Which of the following options best describes how you think of yourself?
Which of the following options best describes how you think of yourself?
Is your gender identity the same as the gender you were given at birth?

Please note, If you are male we will generally refer to you as Mr. in correspondence, and if you are female, as Miss, Mrs., or Ms., depending upon your preference. Other professional titles such as Dr., Prof, Sir/Dame, Rev. will only generally be used in written correspondence. If you prefer a non-binary title, we can use the title Mx.

I prefer the title Mx.

Next of Kin

Previous Details

Please include postcode.

If you are from abroad

Registering with the NHS for the first time in the UK
Please use this date format: DD/MM/YYYY.

If you are returning from abroad

Previously been registered with the NHS in the UK
Please use this date format: DD/MM/YYYY.
Please use this date format: DD/MM/YYYY.

Health Conditions

Please tick the relevant boxes below, if you have any of the conditions listed:

Lifestyle

Do you smoke?
Would you like some advice to help you quit smoking?

Alcohol Intake

How often do you have a drink containing alcohol? *
How many units of alcohol do you drink on a typical day when you are drinking? *
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? *

Alcohol Intake Part Two

How often during the last year have you found that you were not able to stop drinking once you had started? *
How often during the last year have you failed to do what was normally expected from you because of your drinking? *
How often during the last year have you needed an alcoholic drink in the morning to get yourself going after a heavy drinking session? *
How often during the last year have you had a feeling of guilt or remorse after drinking? *
How often during the last year have you been unable to remember what happened the night before because you had been drinking? *
Have you or somebody else been injured as a result of your drinking? *
Has a relative or friend, doctor or other health worker been concerned about your drinking or suggested that you cut down? *

Carers

Are you a registered carer?
Do you have a carer?
Are you a carer aged under 18?

Female Patients Only

Please use this date format: DD/MM/YYYY
Please use this date format: DD/MM/YYYY
Have you had a hysterectomy?
Please use this date format: DD/MM/YYYY

Online Access

We would like to automatically enrol you to have online access to appointments/prescriptions. If you would like to opt out of these services please advise the receptionists.

Nominate a Pharmacy

Please nominate a pharmacy so that your prescriptions can go directly to the pharmacy.

The Accessible Information Standard

The Accessible Information Standard aims to ensure that patients (or their carers) who have a disability or sensory loss can receive, access and understand information, for example in large print, braille or via email, and professional communication support if they need it, for example from a British Sign Language interpreter.

This applies to patients and their carers who have information and / or communication needs relating to a disability, impairment or sensory loss. It also applies to parents and carers of patients who have such information and / or communication needs, where appropriate.

Individuals most likely to be affected by the Standard include people who are blind or deaf, who have some hearing and / or visual loss, people who are deaf blind and people with a learning disability. However, this list is not exhaustive.

Do you have communication needs?
Do you need a format other than standard print?
Do you have any special communication requirements?
Does your carer need communication assistance?
Do you consent to the practice contacting your main carer regarding your carer?
Signature type