Register - Adult (16+) - Manor View Practice

New Patient Registration – Adult (16 Years Old & Over)

Personal Details

Please specify title

First name

Middle name

Last name

Known as

Previous last name (if applicable)

Date of birth

NHS number (providing this will speed up registration)

Gender

Male Female Intersex

Background Information

Marital status

Religion

Ethnicity

Do you speak English?

Yes No

Do you read English?

Yes No

What is your first language?

Please specify language

Do you require an interpreter?

Yes No

Have you ever been registered with Manor View Practice before?

Yes No

Are you registering for a temporary time?

Yes No

When are you likely to leave us?

Home Address

Home address

Post code

Town and country of birth

Contact Details

Primary phone

Home phone

Mobile phone

Email address

Do you have any communication needs? E.g. large print or specific coloured paper.

Yes No

Preferred communication method

Telephone Text Email Post

Notification Consent

Do you consent to us contacting you by text?

Yes No

Do you consent to us contacting you by email?

Yes No

Previous Details

Do you have a previous UK address?

Yes No

Previous home address

Previous post code

Have you previously been registered with another GP practice in the UK?

Yes No

Previous GP address

Previous GP post code

Are you registering with a GP practice for the first time in the UK?

Yes No

Date you came to the UK

First UK address

First UK post code

Are you returning from abroad?

Yes No

Date you left the UK

Date you returned to the UK

Carers

Are you a carer for someone?

Yes No

Do you have a carer?

Yes No

Name of carer

Phone number of carer

Address of carer

Do you give us permission to discuss your medical records with your carer?

Yes No

Armed Forces

Are you an Armed Forces veteran

Yes No

Were you ever registered with an Armed Forces GP?

Yes No

Address before enlisting

Service or personnel number

Enlistment date

Discharge date (if applicable)

Lifestyle

We recommend that patients obtain accurate weight, height, weight and blood pressure measurements using the machine in reception (available at both sites)

Smoking status

Current smoker Ex smoker Never smoked

How many per day

How often have you had 6 or more units (female) or 8 or more (male) on a single occasion in the last year?

Medical History

Sight and hearing adjustments can be made at the practice

How is your sight?

Good Poor Registered blind

How is your hearing?

Good Poor Partially deaf Registered deaf

Are you registered disabled?

Yes No

Please give details of your disability

Are you allergic to any medicine?

Yes No

Which medicines?

Do you have any other allergies?

Yes No

Please give details of what you are allergic to, what happens and when you had your first reaction

Are you currently taking any regular medications?

Yes No

Please give details of any current medications you are taking

Electronic Prescribing

The Electronic Prescription Service (EPS) is an NHS service that sends electronic prescriptions from GP practices to pharmacies allowing you to choose where you get your medications or appliances from.

Would you like to nominate a pharmacy for electronic prescribing?

Yes No

Name and address of nominated pharmacy

Latent Tuberculosis Testing

The Practice is working with Public Health England, NHS England, Acute Hospitals and Local Authorities to deliver a comprehensive service to:

Screen, identify and treat patients with latent tuberculosis (TB) infection
To reduce the spread of the disease
To reduce activation of TB and thereby reduce the spread of TB

Please would you answer the following questions:

If you have ticked any country above, please complete the following:

Have you entered the UK within the last 5 years (including where entry was via other countries (e.g. within EU/EEA)

Yes No Not applicable

Are you aged 16-35?

Yes No Not applicable

Have you ever been treated for TB or do you have untreated TB?

Yes No Not applicable

Have you ever been screened for TB in the UK?

Yes No Not applicable

Declaration

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 have access to your records are 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.

My Data Matters

If you do NOT wish the NHS to share data from your health records for the purposes of research and planning, please opt out on the NHS website.

Summary Care Records (SCR)

These are an electronic record of important patient information, created from GP medical records. They can be seen and used by authorised staff only; in other areas of the health and care system involved in the patients care.

To opt out, visit www.digital.nhs.uk/scr

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

Privacy Policy

This form collects your name, date of birth, email, other personal information and medical details. This is to confirm you are registered with the practice, to allow the practice team to contact you and also to update your medical records held by the practice and our partners in the NHS. Please read our Privacy Policy to discover how we protect and manage your submitted data.