Practice Area
How to Register
Guide to GP Services
Non – English Speakers

Practice Area

Catchment Area

How to Register

If you live within the Practice Area and wish to register with us, please complete the relevant registration form along with the GMS1 form below.

Registration Form (Adult)

Step 1 of 2

50%

Please Note: A supporting signed letter from the patient will be required either posted or emailed to the practice, to complete the registration.

Background Details

Contact Details

NHS Number Optional

If you do not have a NHS number what is the date you came to the UK? Optional

MM slash DD slash YYYY

Name

Prefix

Name

First Middle Last

Previous Surname (if applicable) Optional

Gender

Date of Birth

Day

Month

Year

Home Telephone Optional

Mobile Number

Do you content to be contacted via SMS?

Address

Street Address Address Line 2 City Post code

Previous Address

Street Address Optional Address Line 2 Optional City Optional Post Code Optional

Enter Email Confirm Email

Do you consent to be contacted Via email?

Occupation Optional

Next of Kin

Do you have a next of kin?

(emergency contact person)

Name

First Last

Phone

Relationship to you

Previous GP

GP Name

Address

Street Address Address Line 2 City Post Code

Other Details

Country of Birth

Ethnicity

Religon Optional

Communication Needs

What is your main spoken language?

Do you need an interpretor?

Do you have any communication needs?

Do you have a learning disability?

Carer Details

Do you have a Carer?

Are you a Carer?

Medical History

Have you suffered from any of the following conditions?

Any other conditions, operations or hospital admission details: Optional

If you are currently under the care of a Hospital or Consultant outside our area, please tell us here: Optional

Family History

Please record any significant family history of close relatives with medical problems and confirm which relative e.g. mother, father, brother, sister, grandparent.

Relative Optional

i.e Parent, Sibling, Grandparent, Aunt/Uncle/Cousin etc

Medical Problem Optional

Allergies

Please record any allergies or sensitivities

Medication

Please check and include as much information about your current medication below.

Please give us your previous repeat medication list if possible, a medication review appointment may be needed: Optional

Your Lifestyle

How many times a week do you exercise for more than 30 minutes?

Alcohol

Please answer the following questions which are validated as screening tools for alcohol use: AUDIT–C QUESTIONS Please check the correct boxes and check your score. (Scores can be found to the right of your answer)

How often do you have a drink containing Alcohol?

Units

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?

A score of less than 5 indicates lower risk drinking

Scores of 5 or more require the following 7 questions to be completed:

Total Score:

4 or less

5 or more

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?

Total Score?

Smoking

Do you smoke?

How many cigarettes did/do you smoke a day?

Would you like help to quit smoking?

For further information, please see:
www.nhs.uk/smokefree

Height and Weight

Height

Weight

Women's Health

Are you Female?

Do you use any contraception?

Are you currently pregnant or think you may be?

Expected due date

Day

Month

Year

Students

Students are at risk of certain infections including mumps, meningitis and sexually transmitted infections, as well as mental health issues including stress, anxiety and depression.
For further information, please see:
www.nhs.uk/Livewell/Studenthealth

Are you a student?

I am less than 24 years old and have had two doses of the MMR Vaccination

I am less than 25 years old and have had a Meningitis C Vaccination

Electronic Prescribing

If you would like your prescriptions to be sent electronically, please provide details of the pharmacy you would like to use: Optional

PPG – Patient Participation Group

Would you like to be involved in our Patient Participation Group?

Blood and Organ Donation

Blood Donation

I am already a blood donor

I wish to be a blood donor

I do not wish to be a blood donor

Organ Donation

I am already registered as a donor

I wish to be a donor – all body part

I wish to be a donor – for these body parts:

I do not wish to be a donor

Which organs would you like to donate: Optional

You can register Online

-OR-

You can call(030 0123 2323) and speak to an advisor who will send out a donor card.

I confirm that the information I have provided is true to the best of my knowledge.

Name

Date

Day

Month

Year

Your Health Record

Do you consent to your GP Practice sharing your health record with other organisations who care for you?

I wish to give EXPRESS CONSENT for medication, allergies and adverse reactions only to be included in my Summary Care Record

I wish to give EXPRESS CONSENT for medication, allergies, adverse reaction and additional information to be included in the my Summary Care Record

I DO NOT CONSENT to have my Summary Care Record and do not wish to have one

Do you consent to your GP Practice viewing your health record from other organisations that care for you?

Yes (recommended option)

Your Summary Care Record (SCR)

Do you consent to having an Enhanced Summary Care Record with Additional Information?

Yes (recommended option) Optional

No Optional

I wish to have online access to:

Please tick all that apply

View & book appointments

View & request medication

Access my coded medical record (contains any medical codes that have been recorded)

Access my full medical record (contains medical codes and any free text that has been recorded)

Access my Summary Care Record

Complete online questionnaires

I wish to access my medical record and understand and agree with each statement:

Please tick all that apply

I have read and understood the ‘Important Information’ section below

I will be responsible for the security of the information that I see or download

If I choose to share my information with anyone else, this is at my own risk

I will contact the practice as soon as possible if I suspect that my account has been accessed by someone without my agreement

If I see information in my record that it not about me, or is inaccurate I will log out immediately and contact the practice as soon as possible

Access to GP Online Services

Important Information – Please read before completing form below

If you wish to, you can now use the internet (via computer or mobile app) to book appointments with a GP, request repeat prescriptions for any medications you take regularly and look at your medical record online. You can also still use the telephone or call in to the surgery for any of these services as well. It’s your choice.

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. If you are unable to do this for some reason, we recommend that you contact the practice so that they can remove online access until you are able to reset your password.

If you print out any information from your record, it is also your responsibility to keep this secure. If you are at all worried about keeping printed copies safe, we recommend that you do not make copies at all.

During the working day it is sometimes necessary for practice staff to input into your record, for example, to attach a document that has been received, or update your information. Therefore you will notice admin/reception staff names alongside some of your medical information – this is quite normal.

The definition of a full medical record is all the information that is held in a patient’s record; this includes letters, documents, and any free text which has been added by practice staff, usually the GP. The coded record is all the information that is in the record in coded form, such as diagnoses, signs and symptoms (such as coughing, headache etc.) but excludes letters, documents and free text.

Before you apply for online access to your record, there are some other things to consider. Although the chances of any of these things happening are very small, you will be asked that you have read and understood the following before you are given login details.

Forgotten history

There may be something you have forgotten about in your record that you might find upsetting.

Abnormal results or bad news

If your GP has given you access to test results or letters, you may see something that you find upsetting to you. This may occur before you have spoken to your doctor or while the surgery is closed and you cannot contact them.

Choosing to share your information with someone

It’s up to you whether or not you share your information with others – perhaps family members or carers. It’s your choice, but also your responsibility to keep the information safe and secure.

Coercion

If you think you may be pressured into revealing details from your patient record to someone else against your will, it is best that you do not register for access at this time.

Misunderstood information

Your medical record is designed to be used by clinical professionals to ensure that you receive the best possible care. Some of the information within your medical record may be highly technical, written by specialists and not easily understood. If you require further clarification, please contact the surgery for a clearer explanation.

Information about someone else

If you spot something in the record that is not about you or notice any other errors, please log out of the system immediately and contact the practice as soon as possible.

For further information, please see:
www.nhs.uk/NHSEngland/AboutNHSservices/doctors/Pages/gp-online-services.aspx

Date Optional

MM slash DD slash YYYY

Registration Form (Child)

Please upload birth certificate/proof of guardianship. Please also provide copies of immunisations (if aged under 5) *

Drop files here or

Max. file size: 50 MB.

Background Details

Your Child’s Details

Title

NHS Number

First Name

First

Surname

Last

Gender

Date of Birth

Day

Month

Year

Address

Street Address Address Line 2 City Postcode

Contact Number

Parent or Guardian Details

Your Name

Relationship to Child

Address

Street Address Address Line 2 City Postcode

Home Telephone Optional

Work Telephone Optional

Mobile Telephone

Do you consent to be contacted by SMS?

Yes

Do you consent to be contacted by email?

Yes

Family Registered with Us Optional

Other Details

Previous GP

Name of Previous GP

Address

Street Address Address Line 2 City Postcode Country

Childs Other Details

Country of Birth

Ethnicity

White (UK)

White (Irish)

White (Other)

Black Caribbean

Black African

Black Other

Bangladeshi

Indian

Pakistani

Chinese

Other

Religion

C of E Optional

Catholic Optional

Other Christian Optional

Buddhist Optional

Hindu Optional

Muslim Optional

Sikh Optional

Jewish Optional

Jehovah’s Witness Optional

No Religion Optional

Other Optional

Is your child an Overseas Visitor?

Yes

European Health Insurance Card Held (please bring details with you)

Do you have any family members in the Armed Forces?

Yes

Please give details of family members who are in the Armed Forces:

Communication Needs

Language

What is your childs main spoken language?

Do you need an interpreter?

Yes

Communication

Does your child have any communication needs?

Yes

Please specify

Hearing aid

Lip reading

Large print

Braille

British Sign Language

Makaton Sign Language

Guide dog

Learning Disability

Does your child have a Learning Disability?

Yes

(If yes please request a Learning Disability Screening Tool form)

Medical History

Has your child suffered from any of the following conditions?

Asthma Optional

COPD Optional

Epilepsy Optional

Heart Disease Optional

Heart Failure Optional

High Blood Pressure Optional

Diabetes Optional

Kidney Disease Optional

Stroke Optional

Depression Optional

Underactive Thyroid Optional

Cancer Optional

For Cancer, please specify which type

Any other conditions, operations or hospital admission details: Optional

If your child is currently under the care of a Hospital or Consultant outside our area, please tell us here: Optional

Family History

Please record any significant family history of close relatives with medical problems and confirm which relative e.g. mother, father, brother, sister, grandparent.

Medical problem

Asthma Optional

COPD Optional

Epilepsy Optional

Heart Disease Optional

Stroke Optional

Blood Pressure Optional

Diabetes Optional

Kidney Disease Optional

Liver Disease Optional

Depression Optional

Thyroid Optional

Cancer Optional

Other Optional

For Other please specify below Optional

Relative

Father Optional

Mother Optional

Brother Optional

Sister Optional

Grandmother Optional

Grandfather Optional

Extended Family member (Aunt/Uncle/Cousin) Optional

Allergies

Please record any allergies or sensitivities below Optional

Current Medication

Please check and include as much information about your child’s current medication below.

If they have a previous repeat medication list please give this to us and they may need a medication review appointment: Optional

Further Details

Electronic Prescribing

If you would like your child's prescriptions to be sent electronically, please provide details of the pharmacy you would like to use: Optional

Parent or Guardian Signature Optional

Please provide your full name

Sharing Your Childs Health Record

Do you consent to your GP Practice sharing your child's health record with other organisations who care for you?

Yes (recommended)

No – Never

Do you consent to your GP Practice viewing your child's health record from other organisations that care for you?

Yes – (recommended)

Your Childs Summary Care Record (SCR)

Do you consent to your child having an Enhanced Summary Care Record with Additional Information?

Yes – (recommended)

Parent or Guardian Signature

Please provide your full name

Date

Day

Month

Year

Comments Optional

This field is for validation purposes and should be left unchanged.

GMS1 Form

GMS1

Step 1 of 2

50%

Title

Mrs

Miss

Other

NHS Number: Optional

Surname:

First Names:

Prev Surname: Optional

Date of Birth

Day

Month

Year

Sex:

Male

Female

Ethnicity:

First Spoken Language:

Town and Country of Birth:

Address

Street Address Address Line 2 City Post code

Telephone Number

Mobile Number

Email Address

Enter Email Confirm Email

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

Previous Address

Street Address Optional Address Line 2 Optional City Optional Post Code Optional

Name of Doctor while at that address Optional

Address of previous doctor

Street Address Optional Address Line 2 Optional City Optional Post code Optional

Are you from abroad?

Yes Optional

No Optional

Are you in the Armed Forces?

Yes Optional

No Optional

If you are from abroad:

Your first address where registered with a GP

Street Address Optional Address Line 2 Optional City Optional ZIP / Postal Code Optional Country Optional

If previously resident in UK, date of leaving Optional

DD slash MM slash YYYY

Date you first came to live in the UK Optional

DD slash MM slash YYYY

If you are from the Armed Forces:

Address before enlisting

Street Address Optional Address Line 2 Optional City Optional ZIP / Postal Code Optional Country Optional

Service or Personnel number Optional

Enlistment date Optional

DD slash MM slash YYYY

Discharge date Optional

DD slash MM slash YYYY

If registering a child under 5:

I wish the child above to be registered with the doctor named overleaf for Child Health Surveillance. Optional

If you need your doctor to dispense medicines and appliances:

Not all doctors are authorised to dispense medicines.

I live more than 1 mile in a straight line from the nearest chemist. Optional

I would have serious difficulty in getting them from the chemist. Optional

NHS Organ Donor registration:

Please tick as appropriate:

Any part of my body Optional

Or only my:

Kidneys Optional

Heart Optional

Liver Optional

Corneas Optional

Lungs Optional

Pancreas Optional

NHS Blood Donor registration

I would like to join the NHS Blood Donor Register as someone who may be contacted and would be prepared to donate blood. Optional

Tick here if you have given blood in the last 3 years. Optional

Emergency Contact

Name:

Relationship: Optional

Contact Number:

Address

Street Address Address Line 2 City Post Code

I have filled in this form on behalf of

NEW PATIENT QUESTIONNAIRE

Please answer these questions to the best of your ability and hand this questionnaire into the receptionist. The information will be used to update your personal medical record.

Name

Date Of Birth

Day

Month

Year

Phone Number

Email Address

Height

Weight

What is your smoking status?

How many cigarettes do you smoke a day?

When did you stop smoking?

DD slash MM slash YYYY

Do you drink Alcohol?

How many units a week do you drink?

How often do you have a drink containing Alcohol?

How many units do you drink on a typical day?

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

Do you have any allergies?

Which Drugs/Medication? Optional

What are your allergies?

Are you on any regular medication?

What medication?

Have you recently come to the U.K. from a country which has a high incidence of tuberculosis e.g. Lithuania or Romania?

If you have had a cough or any unexplained weight loss recently please make an appointment to see one of the doctors.

From which Country? Optional

Are you a student?

Have you had your MeningitusACWY vaccination?

Section Break

SUMMARY CARE RECORD – your emergency care summary

NHS England has introduced the Summary Care Record, which will be used in emergency care. The record will contain 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 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, healthcare staff treating you will have immediate access to important information about your health.

GP practices are supporting Summary Care Records and as a patient you have a choice:

For more information talk to the Patient Advice and Liaison Service (PALS), GP practice staff, visit the website www.nhscarerecords.nhs.uk or telephone the dedicated NHS Summary Care Record Information Line on 0300 123 3020. You can choose not to have a Summary Care Record and you can change your mind at any time by informing your GP practice. If you do nothing we will assume that you are happy with these changes and create a Summary Care Record for you. Children under 16 will automatically have a Summary Care Record created for them unless their parent or guardian chooses to opt them out. If you are the parent or guardian of a child under 16 and feel that they are old enough to understand, then you should make this information available to them.

The Department of Health has asked us to record the ethnic origin, and first language, of all new patients. Please tick the box which most accurately describes you:

White – British

White – Irish

Other White background

White/Black Caribbean

White/Black African

White/Asian

Other mixed background

Chinese

Indian/British Indian

Pakistan/British Pakistan

Bangladesh/British Bangladesh

Other Asian background

Caribbean/British Caribbean

African/British African

Other Black background

Other ethnic background

Prefer not to say

What is your first main spoken language?

Will you need a translator when you see one of our medical team?

THANK YOU FOR TAKING THE TIME TO COMPLETE THIS QUESTIONNAIRE

Guide to GP Services

The Royal College of General Practitioners has produced a useful guide for patients about the services on offer at GP Surgeries and how to access them. You can download the guide below.

Download A Patient Guide to GP Services

Non – English Speakers

These fact sheets have been written to explain the role of UK health services, the National Health Service (NHS), to newly-arrived individuals seeking asylum. They cover issues such as the role of GPs, their function as gatekeepers to the health services, how to register and how to access emergency services.

Special care has been taken to ensure that information is given in clear language, and the content and style has been tested with user groups. Open the leaflets in one of the following languages.

English	Urdu
Albanian	Hindi
Arabic	Lithuanian
Bulgarian	Polish
Chinese (Cantonese)	Portuguese
Chinese (Mandarin)	Spanish
Russian	French
Turkish	Punjabi
Gujerati	Somali
Croatian	Bengali
Farsi