New Patient Registration Form (Aged 17 and above) - City View Medical Practice & Shafton Lane Surgery

"*" indicates required fields

Personal Details

Title*

Mrs

Miss

Other

Please Specify*

NHS Number*

(If unknown, enter “unknown”)

First Names*

Surname*

Previous Surname Optional

Date of Birth*

Day

Month

Year

Sex*

Female

Male

First Spoken Language*

Country of Birth*

Have you checked you are living within the practice catchment area and are eligible to register?*

Yes

To check your address please click the link below then enter you postcode into the search box on our boundary map.
Catchment Area Map

Current Address*

Street Address Address Line 2 City Postcode

Main Contact Number*

Home Contact Number*

Email Address

Enter Email Optional Confirm Email Optional

We send out appointment reminders and general information via SMS, do you consent to being contacted by the details entered above?*

Yes

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

Do you have a previous UK address?*

Yes

Your previous address in the UK*

Street Address Address Line 2 City Postcode

Your previous address abroad*

Street Address Address Line 2 City County / State / Region ZIP / Postal Code Country

Name of doctor while at that address*

Address of previous doctor

Street Address Optional Address Line 2 Optional City Optional Postcode Optional

Are you from abroad?*

Yes

Your first UK address where registered with a GP*

Street Address Address Line 2 City Postcode

If previously resident in UK, date of leaving*

Day

Month

Year

Date you first came to live in the UK*

Day

Month

Year

Identification and Proof of Address

Identification*

Max. file size: 50 MB.

Accepted forms: Passport, Driving License etc

Proof of Address*

Max. file size: 50 MB.

Accepted Forms: Bank Statement, Utility Bill, Official Documents etc

Supplementary Questions

Are you ordinarily a resident in the UK?*

Yes

PATIENT DECLARATION for all patients who are no ordinarily resident in the UK*

I understand that I may need to pay for NHS treatment outside of the GP Practice

I understand I have a valid exemption from paying for NHS treatment outside of the GP practice. This includes for example, an EHIS, or payment of the Immigration Health Charge (“ the Surcharge”), when accompanied by a valid visa. I can provide documents to support this when requested.

I do not know my chargeable status

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 from your GP practice.
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.
Please tick one of the boxes above.

European Economic Area (EEA) Country

For a list of EEA countries visit: www.gov.uk/eu-eea

Do you live in another EEA country, or have moved to the UK to study or retire, or live in the UK but work in another EEA member state?

Yes Optional

No Optional

Women

Have you ever had a cervical smear?

Yes Optional

No Optional

Date of last smear test*

Day

Month

Year

Where did you have your smear test?*

What was the result your smear test?*

Demographics

Marital Status*

Single, never married

Married

Civil Partnership

Divorced

Widowed

Separated

Which of the following options best describes you?*

Heterosexual or Straight

Gay or Lesbian

Bisexual

Prefer not to say

In another way

Sex and gender identity – Which one of the following best describes how you think of yourself?*

Male (including trans men)

Female (including trans women)

Non-binary

Prefer not to say

In another way

Is your gender identity the same as the gender you were given at birth?*

Yes

Prefer not to say

Ethnic Origin Optional

Please Specify*

What is your main religion?

No religion Optional

Christian (including Church of England, Catholic, Protestant, and all other Christian denominations) Optional

Buddhist Optional

Hindu Optional

Jewish Optional

Muslim Optional

Sikh Optional

Other religion (Please Specify) Optional

religion*

(Please Specify)

Communication Needs

Do you speak English?*

Yes

Do you read English?*

Yes

Do you need an translator?*

Yes

Are you a British Sign Language user?*

Yes

What is your main spoken language?*

Do you have any further specific information or communication needs? If so, please specify how we can meet these for you (e.g. large print, Braille, easy read communications) Optional

Pregnancy

Are you pregnant?*

Yes

How many weeks?*

Disability

Do you have an impairment, health condition or learning difference that has a substantial or long term (over a year) impact on your ability to carry out day to day activities? (Tick all that apply)

No known impairment, health condition or learning difference Optional

A long standing illness/health condition such as cancer, HIV, diabetes, chronic heart disease, asthma, or epilepsy Optional

A mental health impairment, such as depression, schizophrenia or anxiety disorder Optional

A physical impairment or mobility issues, such as difficulty using your arms or using a wheelchair or crutches Optional

A learning difficulty Optional

Neuro-diverse e.g. dyslexic, dyspraxic or AD(H)D Optional

Deaf or hearing impaired Optional

Blind or have a visual impairment uncorrected by glasses Optional

An impairment, health condition or learning difference that is not listed above Optional

Prefer not to say Optional

Armed Forces

Have you served in the UK Armed Forces and/or been registered with a Ministry of Defence GP in the UK or overseas?*

Yes

Do you have access to secure housing?*

Yes

What is your current immigration status?*

Asylum Seeker

Failed Asylum Seeker

Not Applicable

Carers

Are you a carer?

Yes Optional

No Optional

A carer is anyone, including children and adults who looks after a family member, partner or friend who needs help because of their illness, frailty, disability, a mental health problem or an addiction and cannot cope without their support.

What are your caring responsibilities?*

Provide details of who you care for*

Do you have a carer?*

Yes

Provide details of who cares for you*

Emergency Contact

Would you like to nominate anyone as your "emergency contact"?

Yes Optional

No Optional

Full Name*

Relationship to you*

Contact Number*

Are they your next of kin?*

Yes

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

Yes

About You

Height Optional

Weight Optional

Smoking Status*

Current Smoker

Ex Smoker

Never Smoked

What do you smoke?*

e.g. Cigarettes, Vape, Cigars

How many do you smoke per day?*

Are you interested in advice on how to quit?*

Yes

Please state how much exercise and what type of exercise you do per week Optional

Alcohol Consumption

This is one unit of alcohol:

Half pint of regular Beer/Lager/Cider
1 small glass of wine
1 single measure of spirits
1 single measure of aperitifs
1 small glass of sherry

Each of these is more than one unit:

Pint of regular Beer/Lager/Cider (2 Units)
Pint of Premium Beer/Lager/Cider (3 Units)
Alcopop or can/bottle of regular Lager (1.5 Units)
Can of Premium Lager/Strong Beer (2 Units)
Can of super strength lager (4 Units)
Glass of wine (2 Units)
Bottle of wine (9 Units)

How often do you have a drink containing alcohol?*

Never

Monthly or less

2-4 times per month

2-3 times per week

4+ times per week

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

1-2

3-4

5-6

7-9

10+

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?*

Never

Less than monthly

Monthly

Weekly

Daily or almost daily

Medical History

Do you have any significant family history we should be aware of? Optional

Major Illnesses Optional

Please include dates

Past Operations Optional

Please include dates

Family History Illnesses Optional

Please include dates

Current Medication Optional

We routinely offer HIV screening, would you be interested in being screened?*

Yes

Sight*

Good

Poor

Registered Blind

Hearing*

Good

Poor

Partially Deaf

Deaf

Are you over 75 years old?*

Yes

The Department of Health has advised that all patients of 75 years 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.

Allergies

Do you have any allergies?*

Yes

Please specify what you are allergic to, what happens and when you had your first reaction*

Immunisation History

Please list any immunisations/vaccinations you have had Optional

Please include dates

Summary Care Record

This record will contain summary information about any medicines you are taking, allergies you suffer from and any bad reactions to medicines you have had to ensure those caring for you have enough information to treat you safely.

Your Summary Care Record will be available to authorised healthcare staff providing you with care anywhere in England, but they will ask your permission before they look at it. This means that if you have an accident or become ill away from home, healthcare staff treating you will have immediate access to important information about your health.

Do you consent to having a Summary Care Record?*

Express consent for medication, allergies, adverse reactions and additional information

Express consent for medication, allergies and adverse reactions only

Express dissent for Summary Care Record (opt out)

Your Medical Information – Sharing Your Data

Under the General Data Protection Regulations (GDPR), we have a responsibility to keep your medical records confidential. We need your consent to share this with other authorised health professionals involved in your care or in planning your care. You can find more information on the website at www.nhs.uk/your-nhs-data-matters.

Please see the privacy notice on our website for more information on how your data is held and used by the practice.

The NHS wants to make sure you and your family has the best care now and in the future. Your health and adult social care information supports your individual care. It also helps us to research, plan and improve health and care services in England.

There are very strict rules on how this data can and cannot be used, and you have clear data rights. We are committed to keeping patient information safe and will always be clear on how it is used.

You can choose whether or not your confidential patient information is used for research and planning.

If you do not wish your information to be used in this way please opt-out by visiting NHS: Your Data Matters or by calling 0300 303 5678. The practice is unable to record this for you.

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.

Online Services

For anyone aged 16 and over, we offer online services repeat prescription ordering and eConsultations. This is the quickest and easiest way to order your medication. Once registered, you will also be able to view your summary record, detailing current medication, allergies and vaccinations.

You will soon receive an email from the practice with your log in details.

These are confidential: It is your responsibility to ensure they can be received securely by email.

Prescriptions are sent electronically to your nominated pharmacy. We will automatically nominate the pharmacy closest to your post code as part of your registration. If you prefer to use a different chemist please contact the practice to sign up for the Electronic Prescribing Service

Would you like to register for online service?*

Yes

Signature

Declaration

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

Signature*

Your Full Name