New Patient Registration - Stroud Green Medical Clinic

You should only send this form if you are sure that you are eligible to join this practice.

Sending this form will not automatically register you with the surgery.

Your details will be held at the surgery for a limited period of time.

Sending this form does not guarantee or even imply that you will be accepted onto the practice register.

You should only send this form if you are sure that you are eligible to join this practice. Sending this form will NOT automatically register you with the surgery. Your details will be held at the surgery for a limited period of time. Sending this form does NOT guarantee or even imply that you will be accepted onto the practice register.

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Patients Details

Preferred Title

Your Name

First Name Surname

Previous Surnames Optional

(if applicable)

Date of Birth

Day

Month

Year

NHS Number Optional

(If known)

Gender

Country and Town of birth

Borough of Birth

Home Address

Street Address Address Line 2 City Postcode

(Please also provide flat number or room number where appropriate)

Home Telephone Number Optional

Mobile Telephone Number

Email Address

Enter Email Confirm Email

Further Details

Religion

(If none enter “None”)

Marital Status

Ethnicity

Please specify your ethnicity

What is your first language?

Do you require an interpreter?

Are you a student?

Yes

Where are you studying?

Occupation

Contacting you

We will from time to time have to contact patients via SMS text message. this is extremely helpful particularly in the current state of pandemic.

Do you agree that you may be contacted from time to time, via email and/or SMS, with practice news, advice about my health and/or appointment reminders?

Yes

Previous Medical Records

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

Have you registered with the NHS before?

Yes

Your previous address in the UK

Street Address Address Line 2 City Postcode

(Enter N/A if not applicable)

Name of previous doctor while at that address

(Enter N/A if not applicable)

Address of previous doctor

Street Address Optional Address Line 2 Optional City Optional Postcode Optional

(Enter N/A if not applicable)

Are you from abroad?

Yes

Your first UK address where registered with a GP

Street Address Address Line 2 City Postcode

(Enter N/A if not applicable)

If previously resident in UK, date of leaving

Day

Month

Year

Date you first came to live in the UK

Day

Month

Year

Are you returning from the Armed Forces?

Yes

Address before enlisting in Armed Forces

Street Address Address Line 2 City Postcode

Service or Personnel number

Enlistment Date

Day

Month

Year

Dispensing Of Medicines And Appliances

If you need a doctor to dispense medicines and appliances

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

I would have serious difficulty in getting them from a chemist Optional

(Not all doctors are authorised to dispense medicines)

Organ & Blood Donation

Would you like to register as an organ donor?

Yes

NHS Organ Donor Registration

I want to register my details on the NHS Organ Donor Register as someone whose organs/tissue may be used for transplantation after my death.

I would like to donate:

Any of my organs and tissue Optional

Kidneys Optional

Heart Optional

Liver Optional

Corneas Optional

Lungs Optional

Pancreas Optional

Any part of my body Optional

(Please tick the boxes that apply)

Signature

(For more information, please ask at reception for an information leaflet or visit the website www.uktransplant.org.uk, or call 0300 123 23 23)

Are you/Would you like to register as a blood donor?

Yes

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.

Donor Confirmation

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

Signature

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

My preferred address (including postcode) for donation is:

Street Address Optional Address Line 2 Optional City Optional Postcode Optional

(only if different from above, e.g. your place of work)

Supplementary Questions

Are you ordinarily resident in the UK?

Yes

For all patients who are not ordinarily resident in the UK: 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.

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.

(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.)

PATIENT DECLARATION : Please select one of the statements below:

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 EHIC, 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

Patient Declaration Conf

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)

Are you completing this form on behalf of a child under 16?

Yes

Signature Optional

Patient's Name

First Name Surname

(if signing for the person named at the top of this form)

Relationship to patient

(if signing for the person named at the top of this form)

Non-UK European Health Insurance Card (EHIC), Provisional Replacement Certificate (PRC) Details

Complete this section if you live in another EEA country, or have moved to the UK to study or retire, or if you live in the UK but work in another EEA member state. Do not complete this section if you have an EHIC issued by the UK

Do you have a non-UK EHIC or PRC?

Yes

Please enter details from your EHIC or PRC below:

Country code

Name

First Name Optional Surname Optional

Given Names Optional

Date of Birth

Day Optional

Month Optional

Year Optional

Personal Identification Number Optional

Identification Number of the Institution Optional

Identification number of the card Optional

Expiry Date

Day Optional

Month Optional

Year Optional

PRC Validity Period

PRC valid From:

Day Optional

Month Optional

Year Optional

PRC valid til:

Day Optional

Month Optional

Year Optional

S1 Form

Do you have an S1 form? If yes, please give your S1 form to the practice staff.

Yes, I have an S1 form, and I will bring or send it to the practice

No, I do not have an S1 form

(e.g. You are retiring to the UK or you have been posted here by your employer for work or you live in the UK but work in another EEA member state)

How will your EHIC/PRC/S1 data be used? By using your EHIC or PRC for NHS treatment costs your EHIC or PRC data and GP appointment data will be shared with NHS secondary care (hospitals) and NHS Digital solely for the purposes of cost recovery. Your clinical data will not be shared in the cost recovery process.

Your EHIC, PRC or S1 information will be shared with The Department for Work and Pensions for the purpose of recovering your NHS costs from your home country.

Carers

Do you have a carer?

Yes

Please give details

Are you a carer?

Yes

Please give details

Next of Kin Information

Please provide us with information of your Next of Kin – Somebody we can contact in a state of emergency.

Do you have any "Next of Kin" you would like us to contact in the case of an emergency?

Yes

Next of Kin Name

First Last

Next of Kin Address

Street Address Address Line 2 City Postcode

Next of Kin Contact Number

What is this persons relationship to you?

(e.g. Mother, father, sister, cousin, friend etc.)

Consent to discuss your medical records with your Next of Kin if necessary

Yes

Is your Next of Kin a registered patient under the care of Stroud Green Medical Clinic?

Yes

Online access to your medical records

We are offering patients access to their online records. You can view test results, history and request repeat medication without hassle.

Would you like online access?

Yes

Living Will

Do you hold a Living Will?

Yes

Lifestyle

Do you smoke?

Yes

Have you ever smoked?

Yes

If you do currently smoke, how many cigarettes or ounces of tobacco do you smoke per week?

Would you like advice on giving up smoking?

Yes

Do you take regular exercise?

Yes

If 'Yes', what type?

What is your height?

(In CM please)

What is your weight?

(In LBS pelase)

Alcohol

MEN: How often do you have EIGHT or more drinks on one occasion? WOMEN: How often do you have SIX or more drinks on one occasion?

Never

Less than monthly

Monthly

Weekly

Daily

How often during the last year have you failed to do what was normally expected of you because of drinking?

Never

Less than monthly

Monthly

Weekly

Daily

How often during the last year have you failed to do what was normally expected of you because of drinking?

Never

Less than monthly

Monthly

Weekly

Daily

In the last year has a relative or friend, or a doctor or other health worker been concerned about your drinking or suggested you cut down?

Yes, on one occasion

Yes, more than once

Family History

Please state any serious illness, in particular cancer, heart disease, stroke, high blood pressure, diabetes or any inherited disease

Please state your relationship to the individual and in the case of cancer, the type of cancer.

Medical Information

Please complete this section as accurately as possible.

Are you registered disabled?

Yes

If yes, please provide us with details

Are you currently taking any medication?

Yes

Please list any medicines being taken and the amount

Are you allergic to any medicines?

Yes

If so, which?

Please list any serious illnesses / operations / accidents / disabilities (and for women any pregnancy related problems) and the year they took place Optional

If none, please state “None”

Have you ever suffered from?

Epilepsy Optional

Blindness/Glaucoma Optional

High Blood Pressure Optional

Diabetes Optional

Heart Attack/Stroke Optional

Depression Optional

Cancer Optional

Asthma Optional

Eczema/Hay Fever Optional

COPD Optional

None of the above Optional

(tick as appropriate)

If yes, please state the year(s) when were you first diagnosed?

Have you ever refused treatment/screening of any kind?

Yes

If so, what and when?

Have you ever suffered from any of the below?

Anxiety

OCD

Depression

Bipolar Disorder

None of the above

(Please tick as appropriate)

please state the year(s) when you were first diagnosed

Do you have any other mental health conditions/issues?

Yes

Please specify

Are you receiving or have you received any treatment or therapy?

(If none, state “none”, If yes please give details of your care and when you received it)

Women's Health

Were you born with female sexual organs?

Yes

Have you ever had a cervical smear?

Yes

If you have selected "yes", please state the result of your last cervical smear

Date of last cervical smear

Day

Month

Year

Where did you have your last cervical smear?

Have you ever had a hysterectomy?

Yes

(removal of womb)

If yes, when?

Day

Month

Year

Have you ever had a bilateral oophorectomy?

Yes

(removal of ovaries)

If yes, when?

Day

Month

Year

Patient Participation Group

We would like to invite you to join our Patient Participation Group! Do you want to improve health and health services in your local community? Do you want to have the opportunity to have a voice and get involved in the way your health service is run? Do you want to help shape and improve services and even get involved in shaping and delivering new and exciting services?

Would you like to become a member of Patient Participation Group?

Yes

Complete Registration

Please note – If there are queries regarding your registration, we will try to contact you to obtain the relevant information. Your registration may be delayed if we are unable to contact you.

If you are registering a child under 5

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

If you need your doctor to dispense medicines and appliances

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

I would have serious difficulty in getting them from a chemist Optional

Signature

Signature of patient Optional

Signature on behalf of patient Optional

Signed Optional

(Full Name)