New Patient Registration Form – Victoria Medical Centre

Online form

Fields marked * are required. This form is processed by the practice's website form plugin; in this static preview it is display-only.

Title

Full Name

Date of Birth

Marital Status

Gender

Other (Please state)

Mobile number

We will use this to send appointment reminders and health promotion details. Please click here to give your consent for this: We will use this to send appointment reminders and health promotion details. Please click here to give your consent for this:

Work tel. number

Email Address

Maiden name / Mothers name if different:

Next of Kin

Relationship with patient

Kin's tel. number

How would you prefer us to contact you?

Country

Town

Borough (*If born in London)

Please list other residents of your home who are registered with us

Name of the registered person

Registered person's Date of Birth

NHS No.

Town of Birth

Country of birth

Home Address

Please help us trace your previous medical records by providing the following information

Your previous address in UK

Name of previous doctor while at that address

Address of previous doctor

If you are from abroad

Your first UK address where registered with a GP

Date of leaving (If previously resident in UK)

Date you first came to live in UK

If you are returning from the Armed Forces

Address before enlisting

Service or Personnel number

Enlistment date

If you are registering a child under 5 I wish the child above to be registered with the doctor named overleaf for Child Health Surveillance

If you need your doctor to dispense medicines and appliances*

*Not all doctors are authorised to dispense medicines

NHS Organ Donor registration

I would like to join the NHS Organ Donor Register as someone whose organs may be used for transplantation after my death. Please tick as appropriate Kidneys Heart Liver Corneas Lungs Pancreas Any part of my body I do not want to join the NHS Organ Donor Register

Confirm your consent to organ donation Confirm your consent to organ donation

NHS Blood Donor registration

I would like to join the NHS Blood Donor Register as someone who may be contacted and would be pre p a red to donate blood Check this if you have given blood in the last 3 years

For more information, please ask for the leaflet on joining the NHS Blood Donor

Postcode

Are you looking after someone?Let us know if you are looking after someone who is ill, frail, disabled or has mental health and/or emotional support needs, or substance misuse problems Yes No

Is someone looking after you?Let us know if a family member, friend or neighbour looks after you. If yes, they are your carer. You are welcome to invite your carer to accompany you to visits at the practice. Yes No

Carer's Name

Carer's Relationship with you

Carer's Tel. No.

Carer's Address

If so please specify whether

If you are not employed, please indicate which best describes you

Other (Please state)

If returning from the Armed Forces please state which below

Comments (If you have any)

Your ReligionIt’s important to let us know if your religion will affect any treatment you receive

Your Ethnic Origin

Do you need an Interpreter?

If yes, which language?

Other (Please state)

Are you currently?

Are you an ‘Assistance Dog’ User?

Are you housebound?

Lifestyle

Are you currently a smoker?

Have you ever been a smoker?

If you smoke, how many Cigarettes / Cigars / Tobacco do you smoke in a day?

If you are a smoker and want to STOP please tick here If you are a smoker and want to STOP please tick here

Alcohol

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+ if male, on a single occasion in the last year?

*Alcohol Units: 1 Pint Of Premium Beer = 2.5 Units. 1 Pint Beer/Cider = 2 Units. Single Measure Of Spirit = 1 Unit. Small (125ml) Glass Of Wine = 1 Unit

Diet and Exercise

How much exercise do you do?

What type of diet do you have?

Please enter your height in Feet / inches

Please enter your height in CM

Please enter your weight in Kilos/grams

Please enter your weight in Stones/lbs

Women Only

What is the date of your last Smear test?

What is the result of your last Smear test?

Was this at your GP Surgery?

Date of last Mammogram (if applicable)

Number of pregnancies (include miscarriages & terminations) (If applicable)

Do you wish to see a doctor in this Practice for contraceptive services (including the pill, coil or cap)?

Your Medical Background

State the family member if have Diabetes

State the family member if have Asthma

State the family member if haveThyroid disorder

State the family member if have Stroke

State the family member if have COPD

State the family member if have Heart Attack under age of 60

State the family member if have Cancer (Specify type)

State the family member if have High Blood pressure

Please state if someone in your family have any other important illness

Please state any allergies and sensitivities you have to medicines, food & dressings

Please state any mental disabilities you have

Are you able to administer your own medicines?

If no please give details, e.g. swallowing or opening containers

What long term medical conditions have you had?

Date of Diagnosis

What operations or serious injuries have you had?

Date of operations or injuries

Please list any tablets, medicines or other treatments you are currently taking / undertaking:

We can now send your prescriptions electronically to the pharmacy of your choice. If you would like us to do this, please give the name and location of the pharmacy here

Sharing Your Medical Record

Medical Record Sharing allows your complete GP medical record to be made available to authorised healthcare professionals involved in your care. You will always be asked your permission before anybody looks at your shared medical record. Check this if you don’t want to share your GP record

Summary Care Record contains details of your key health information – medications, allergies and adverse reactions. They are accessible to authorised healthcare staff in A&E Departments throughout England. You will always be asked your permission before anybody looks at your Summary Care Record. Check this if you don’t want to have a Summary Care Record

The Care.data Programme Collates information about you and the care you receive. It links information from all the different places where you receive care, such as your GP, hospital and community services, to help them provide a full picture of your medical needs and the care you are receiving. This data is made available to NHS Commissioners so that they can design integrated services and is shared with third parties for research purposes. I wish to OPT OUT from my Personal Confidential Data being shared outside my GP practice I wish to OPT OUT from my Personal Confidential Data being shared with third parties

Patient Participation Group (PPG)

The Practice is committed to improving the services we provide to our patients. To do this, it is vital that we hear from people about their experiences, views, and ideas for making services better. By expressing your interest, you will be helping us to plan ways of involving patients that suit you. It will also mean we can keep you informed of opportunities to give your views and up to date with developments within the Practice. If you are interested in getting involved in the PPG, please tick yes in the box below and we will contact you with further details. Yes I am interested in becoming involved in the PPG No I am not interested in becoming involved in the PPG

Online Services

You can now do the following online or via the SystmOnline appBook and cancel appointments, order repeat prescriptions, view a summary of your medical record.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. Yes I’d like to register for online services No I don’t want to register for online services

Other Information

Do you have a “Living Will”? (A statement explaining what medical treatment you would not want in the future)?

If “Yes”, can you please bring a written copy of it to your first appointment?

Have you nominated someone to speak on your behalf (e.g. a person who has Power of Attorney)?

If “Yes”, please state their details below

Name

Address

Phone number

Online form

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