New Patient Registration Form (Adult: 16 and over) Instructions for completing this form Please complete a separate form for each family member to be registered. "*" indicates required fields Step 1 of 4 25% Personal DetailsName* MrMrsMissMsMx Title First Surname(s) Gender* Male Female Other Date of Birth* Day Month Year NHS Number Optional(if known)Town and Country of Birth* Are you from abroad?* Yes No Date you came to the UK* Day Month Year Date you plan on leaving the UK Day Optional Month Optional Year Optional (if applicable)Have you ever been registered with this practice?* Yes No Current Address* Street Address Address Line 2 City Postcode Mobile Telephone*Home Telephone OptionalWork Telephone OptionalEmail Address* How would you like to be contacted?* Text Email Mail Answerphone Work What is your sexual orientation?* Heterosexual Homosexual Bisexual Rather not say Other Is your gender the same as the gender you were assigned at birth?* Yes No Would you describe yourself as intersex?* Yes No Previous GP DetailsHave you ever been registered with a GP in the UK?* Yes No Name of last GP/surgery* Address of last GP/Surgery Street Address Optional Address Line 2 Optional City Optional Postcode Optional (if known)Your Address while registered with that GP* Street Address Address Line 2 City Postcode Your Next of Kin / Emergency ContactNext of kin's Name* First Last Relationship to you* Contact Number*Next of kin's Address* Street Address Address Line 2 City Postcode NHS Organ and Blood Donor registration (voluntary)If you would like to join the NHS Organ and Blood Donor register visit: www.organdonation.nhs.uk or call 0300 123 2323Your Ethnic GroupPlease choose one of the five options then tick your ethnic group* White Mixed Asian or Asian British Black or Black British Other White* White British White Irish Other Mixed* White and Black Caribbean White and Black African White and Asian Other Asian or Asian British* Indian Pakistani Bangladeshi Other Black or Black British* Black Caribbean Black African Somali Other Other* Chinese Japanese Korean Middle Eastern Other HealthDo you take regular medication?* Yes No Do you have any long-term illness, health problem or disability?* Yes No Height* Weight* When was your last cervical (pap) smear test?* Are there any serious diseases that affect your parents, brothers or sisters?* Diabetes Asthma Thyroid disorder Stroke Heart Attack (under age of 60) Cancer (Specify type) High blood pressure None of the above Any other important family illness Tick all that apply and state family memberPlease specify which family has what serious disease*Please list of any medication you are currently taking*If none, please state with ‘N/A’LifestyleAre you a main carer (unpaid) for someone who has poor health or disability? Yes Optional No Optional Smoking Status Current Smoker Optional Ex-Smoker Optional Never Smoked Optional How much do you smoke per day?* (Cigarettes / Tobacco / Vape)When did you quit?* (Provide a date if possible)How often do you have a drink containing alcohol?* Never 1: Monthly or less 2: 2-4 times per month 3: 2-3 times per week 4: 4+ times per week Alcohol units: Pint of beer/larger/cider = 2 units single spirits (25ml) = 1 unit Glass of wine (175ml) = 2 units Alcopop = 1.5 units How many units of alcohol do you drink on a typical day when drinking?* 0: 1-2 1: 3-4 2: 5-6 3: 7-8 4: 10+ How often have you had 6 or more units if female, or 8 if male, on a single occasion in the last year?* 0: Never 1: Less than monthly 2: Monthly 3: Weekly 4: Daily or almost daily LanguageWhat is your main spoke language?* (Only one)Do you have any problems reading English?* I have no problems I have some problems I have a lot of problems Do you have any problems speaking English?* I have no problems I have some problems I have a lot of problems If English is not your main spoken language, do you need an interpreter (someone to help with language) when you visit the doctor?* Yes No StudiesAre you currently a University student?* Yes No Are you an international Student?* Yes No Which University?* Course End Date* DD slash MM slash YYYY Nominated PharmacyPharmacy Name Optional Pharmacy Address Street Address Optional Address Line 2 Optional City Optional Postcode Optional Online ServicesRegister for online services?* Yes No Patient participation GroupWould you like to become part of our Patient participation Group?* Yes No Summary Care Record – Your Emergency Care SummaryThe NHS in England is introducing 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 that those caring for you have enough information to treat you safely. Your Summary Care Record will be available, in the near future, to authorised healthcare staff providing your care anywhere in England, but they will ask for 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. 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. For further information please ask your practice for an SCR information booklet. You can also talk to our Patient Advice and Liaison Service (PALS) (0800 015 1462), visit the website digital.nhs.uk or telephone the dedicated NHS Summary Care Record Information Line (0300 123 3020) As a patient you have a choice. You can choose not to have a Summary Care Record and you can change your mind at any time by informing your GP practice. Please choose one of the options below* Yes – I want to have a Summary Care Record No – I do not want a Summary Care Record. (I am aware this will mean I have Opt Out for now.) I don’t know whether I want a Summary Care Record and need more time to consider my options. (this will mean I will NOT have an SCR until I inform my Practice otherwise and I am aware this will mean I have Opt Out for now.) Please be advised that we will create your Summary Care Record following your registration with this practice unless you express a preference otherwise. NHS England Data Use Beyond Individual CareHow the NHS and Care Services use your information Whenever you use a health or care service, such as attending Accident & Emergency or using Community Care services, important information about you is collected in a patient record for that service. Collecting this information helps to ensure you get the best possible care and treatment. The information collected about you when you use these services can also be used and provided to other organisations for purposes beyond your individual care, for instance to help with: Improving the quality and standards of care provided Research into the development of new treatments Preventing illness and diseases Monitoring safety Planning services This may only take place when there is a clear legal basis to use this information. All these uses help to provide better health and care for you, your family and future generations. Confidential patient information about your health and care is only used like this where allowed by law. Most of the time, anonymised data is used for research and planning so that you cannot be identified in which case your confidential patient information isn’t needed. You have a choice about whether you want your confidential patient information to be used in this way. If you are happy with this use of your information you do not need to do anything. If you do choose to opt out your confidential patient information will still be used to support your individual care. To find out more or to register your choice to opt out, please visit www.nhs.uk/your-nhs-data-matters. On this web page you will: See what is meant by confidential patient information Find examples of when confidential patient information is used for individual care and examples of when it is used for purposes beyond individual care Find out more about the benefits of sharing data Understand more about who uses the data Find out how your data is protected Be able to access the system to view, set or change your opt-out setting Find the contact telephone number if you want to know any more or to set/change your opt-out by phone See the situations where the opt-out will not apply You can also find out more about how patient information is used at: hra.nhs.uk/information-about-patients/ (which covers health and care research); and understandingpatientdata.org.uk/what-you-need-know (which covers how and why patient information is used, the safeguards and how decisions are made) You can change your mind about your choice at any time. Data being used or shared for purposes beyond individual care does not include your data being shared with insurance companies or used for marketing purposes and data would only be used in this way with your specific agreement. Health and care organisations have until 2020 to put systems and processes in place so they can be compliant with the national data opt-out and apply your choice to any confidential patient information they use or share for purposes beyond your individual care. Our organisation ‘is / is not currently’ compliant with the national data opt-out policy. “ Do you agree to your GP surgery sharing your care data?* I do not agree to my GP surgery sharing data with HSCIC I do agree to my GP practice sharing data with HSCIC I do agree to HSCIC sharing data obtained about me from other health and social care settings with third parties If you wish to change your mind regarding any aspect of this decision at any point in the future, please contact your GP Surgery.