New Patient Registration

 

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Patient's Details

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Information we need to register you with the practice
Please note all fields marked with a * are mandatory for your registration

Ethnicity & Religion
Previous Details
Please include postcode
If you are from abroad
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
Allergies
Were you ever registered with an Armed Forces GP

Footnote: These questions are optional and your answers will not affect your entitlement to register or receive services from the NHS but may improve access to some NHS priority and service charities services

Supplementary Questions

Anybody in England can register with a GP practice and receive free medical care from that practice.

However, if you are not ‘ordinarily resident’ in the UK you may have to pay for NHS treatment outside of the GP practice. Being ordinarily resident broadly means living lawfully in the UK on a properly settled basis for the time being. In most cases, nationals of countries outside the European Economic Area must also have the status of ‘indefinite leave to remain’ in the UK.

Some services, such as diagnostic tests of suspected infectious diseases and any treatment of those diseases are free of charge to all people, while some groups who are not ordinarily resident here are exempt from all treatment charges.

More information on ordinary residence, exemptions and paying for NHS services can be found in the Visitor and Migrant patient leaflet, available at reception. Alternatively for more information go to www.nhs.uk/nhs-services/visiting-or-moving-to-england

You may be asked to provide proof of entitlement in order to receive free NHS treatment outside of the GP practice, otherwise you may be charged for your treatment. Even if you have to pay for a service, you will always be provided with any immediately necessary or urgent treatment, regardless of advance payment.

The information you give on this form will be used to assist in identifying your chargeable status, and may be shared, including with NHS secondary care organisations (e.g. hospitals) and NHS Digital, for the purposes of validation, invoicing and cost recovery. You may be contacted on behalf of the NHS to confirm any details you have provided.

I declare that the information I give on this form is correct and complete. I understand that if it is not correct, appropriate
action may be taken against me.

A parent/guardian should complete the form on behalf of a child under 16.

 
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Lifestyle
Your Personal Alcohol Consumption

alcohol consumption Image 1 unit

 
 
Alcohol unit guidelines

UK alcohol unit guidance: CMOs' Low Risk Drinking Guidelines

To keep health risks from alcohol to a low level, the UK Chief Medical Officers (CMOs) advise it is safest not to drink more than 14 units a week on a regular basis. The CMO also give guidance on drinking in pregnancy and single occasion drinking.

For more information about drinking guidelines and understanding units visit Drink Aware.

 
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Adult Females
Please use this date format: DD/MM/YYYY.
Medical History
Please include dates.
Please include dates.
Please include dates.

Over 75 years old?

The Department of Health has advised that all patients of 75years and older have a named and accountable GP to oversee their care. Please ask the name of the GP assigned to oversee your care. Please note this does not prevent you from seeing the GP of your choice.

 
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Summary Care Record

Summary Care Record (SCR)

The Summary Care Record (SCR) system is designed to help both your GP and any emergency staff you contact when the surgery is closed to treat your health needs more efficiently.

Your information will be shared between your GP practice, our local hospital and Out Of Hours service. This will enable your GP surgery to access results and any visits you have at the hospital quickly and efficiently, but it also means that if you have an emergency and contact the Out Of Hours service or visit A&E they will have access to your current medications as well as allergies and are better able to treat you.

If you do not return this form, a Summary Care Record will be created for you based on implied consent

EMIS Sharing Consent

In addition to the practice opening hours, patients in City & Hackney have access to GPs and Practice Nurses appointments at other GP Practices from 6.30pm - 8.00pm Monday to Friday and from 8.00am - 8.00pm Saturday and Sunday as part of the Extended Hours GP Access Service. Opting in for data sharing will allow us to book you in for evening and weekend appointments when requested.

 
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Identification Upload

Patient Identification

To fully register you at the practice, we need proof of address dated in the last three months (if not possible, please let us know). 

We will not store these documents and we will securely delete / destroy them after our initial verification. 

Acceptable documents: Tenancy agreement, Mortgage statement, Bank statement, Utility bill (date within the past 3 months) etc. 

 
 
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NHS Organ Donor registration

For more information on organ donation please visit: www.organdonation.nhs.uk

NHS Blood Donor registration

If you would like to join the NHS Blood Donor Register as someone who may be contacted and would be prepared to donate blood, please visit their website on: www.blood.co.uk or call direct on 03001232323

What happens to my information?

Personal and medical information about patients registered at this practice are primarily kept electronically, although some is kept in paper form. Some information will be sent to hospital consultants and other health professionals to whom you are referred by your GP in order to provide continued healthcare and obtain treatment for you.

We sometimes use accredited suppliers for our communication with you, for example when we send recall letters for review clinics or medication reviews. All suppliers we use are checked carefully to ensure they comply with strict confidentiality protocols.

To ensure the security of all patient information, all staff that has access to your records is covered by confidentiality clauses in their contracts and the Data Protection Act and the Freedom of Information Act. Our guiding principle is that we hold your records in strict confidence.

I certify that the information I have provided is correct and consent to my personal and medical information being used as stated above.

Privacy Consent

This form collects personal and medical information about you. We use this information to allow the practice team to contact you. Please read our Privacy Policy to discover how we protect and manage your submitted data.

 
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