New patient registration – Grasmere Surgery

Please note that we do not issue Benzodiazepine prescriptions to new patients. Patients taking this kind of medication will be offered a reduction program lasting up to 8 weeks. If you are not willing to comply with this policy, please may we ask you to consider registering with another practice.

Register with us

Before completing this online form, please check to see if you are in our catchment area using the map below.

If your new address is outside the practice area you may need to find a doctor in your new area follow this link to see who is your nearest Doctor.

If your new address is within our practice area please complete the online form below for each new patient wishing to register with our surgery.

New patient registration form

"*" indicates required fields

Step 1 of 8

12%

Hidden

Office use only

Input code and initial once complete

Address checked to see if in our catchment area

Informed of allocated Dr

Pt Allocated a name DR (XacWQ)

Housebound (13CA)

Carer (Ub1ju)

In a nursing home (13F61)

Preferred method of contact coded

Send carer form to complete

Send Consent form to complete

Appointment made - please give date and time:

Form input by (Initials) __________

Patient's details

Title*

Mrs

Miss

Other

First names*

Surname*

Previous surnames*

Please enter N/A if not applicable

Date of birth*

Day

Month

Year

Do you know the NHS number of the person you are registering?*

Yes

NHS Number*

Town and country of birth*

Home address*

Postcode*

Telephone number*

Please confirm who else lives at your home address

Please provide their full name, date of birth and their relationship to you.

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

Your previous address in UK*

Please enter N/A if not applicable

Name of previous GP practice while at that address*

Please enter N/A if not applicable

Address of previous GP practice while at that address*

Please enter N/A if not applicable

If you are from abroad

Your first UK address where registered with a GP*

Please enter N/A if not applicable

If previously resident in UK, date of leaving*

Please enter N/A if not applicable

Date you first came to live in the United Kingdom*

Please enter N/A if not applicable

Were you ever registered with an Armed Forces GP?

Please indicate if you have served in the UK Armed Forces and/or been registered with a Ministry of Defence GP in the UK or overseas

Not been registered with MoD GP

Regular (Ua007)

Reservist (Xabnw)

Army Veteran (XabCL)

Military Veteran (XaX3N)

Royal Air Force Veteran (XadCN)

Royal Marines Veteran (XadCQ)

Royal Navy Veteran (XadCP)

Family member of active service member of the Armed Forces (XadFb)

Family member of active serving member of the Armed Forces Reserves (XadFc)

Address before enlisting

Please enter N/A if not applicable

Service or Personnel number

Please enter N/A if not applicable

Postcode

Please enter N/A if not applicable

Enlistment date

Day

Month

Year

Discharge date (if applicable)

Day

Month

Year

Footnote: These questions are optional and your answers will not affect your entitlement to register or receive services from the NHS but may improve access to some NHS priority and service charities services.

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. Please tick the boxes that apply.

Please tell your family you want to be an organ donor. If you do not want to be an organ donor, please visit www.organdonation.nhs.uk or call 0300 123 23 23 to register your decision.

Kidneys

Heart

Liver

Corneas

Lungs

Pancreas

Any of my organs and tissue

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.

Yes I would like to join the NHS Blood Donor Register

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

My preferred address for donation is: (only if different from above, e.g. your place of work)

All blood types are needed, especially O negative and B negative. Visit www.blood.co.uk or call 0300 123 23 23.

Non-UK European Health Insurance Card (EHIC), Provisional Replacement Certificate (PRC) details and S1 forms

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 state. Do not complete this section if you have an EHIC card issued by the UK.

Do you have a non-UK EHIC or PRC?

If you select yes please complete the additional details from your EHIC card that will appear below.

Yes

Country code*

Name (surname)*

Given names (first names)*

Date of birth*

Day

Month

Year

Personal Identification Number*

Identification number of the institution*

Identification number of the card*

Expiry date*

Day

Month

Year

PRC validity period (a) From:*

Day

Month

Year

PRC validity period (b) To:*

Day

Month

Year

S1 form

Please tick this box if you have an S1 (eg 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). Please give your S1 form to practice staff.

Yes I have an S1 form

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.

More about who you are registering

Who is being registered?*

Please choose the correct age band so we can show you the correct questions below.

Adult over 16 years

Child from 13 to 16 years

Child from 1 to 12 years

Newborn up to 1 year

Adult's mobile number*

This is the Adult's mobile phone number. If the child is over 13 please provide the mobile number for the responsible adult here and the child's mobile in the box below (it is only visible if the correct age is selected above).

Child's mobile number*

Home telephone*

Please enter N/A if not applicable

Email*

Enter Email Confirm Email

Occupation/Job (current/past)*

Please enter N/A if not applicable

Are you retired?*

Yes

Are you homeless?*

Yes

If you are homeless, may we use the address you registered with for confidential post?*

Yes

Next of kin

Next of Kin full name*

Contact number*

Relationship to you*

Please enter N/A if not applicable

Do they have any formal power of attorney for medical care? (if so, please provide the certificates)*

Note, we will only contact this person in case of emergencies, and we will never share confidential information without your consent

Yes

Would you like to give permission for a relative/carer or another person to discuss your confidential information on your behalf?*

If yes, we will send you a separate form to complete.

Yes

More about a child or newborn

Name of person with parental responsibility*

Relationship to you*

Their current home address*

Name of GP surgery at which they are registered*

Name and address of school/nursery attended*

School/nursery phone number*

Language

Do you require an interpreter?*

We offer double appointments for patients who need a language interpreter or BSL. Please ask at reception when booking an appointment.

Yes

Main language spoken*

Lifestyle

Are you a smoker?*

Yes

Never smoked

Ex-smoker

When did you quit?*

If yes, please tick the methods used*

Cigar

Cigarette

E-cigarette

N/A

On average, how many cigarettes/cigars/e-cigarettes do you smoke in a day?*

N/A

10 or less

11-20

21-30

More than 30

Unknown

How soon after waking up do you normally smoke your first cigarette/cigar/e-cigarette?*

N/A

Within 5 minutes

6-30 minutes

31-60 minutes

After one hour

Unknown

How many times have you tried to quit smoking in the past year?*

No quit attempts

Once

2 or 3 times

4 or more times

Unknown

N/A

Is there any other smoking information you wish to provide? Would you want some smoking cessation advice sent to you?

Do you drink alcohol?*

Yes

If yes, how many units per week?*

One unit = 1 small glass of wine, a single measure of spirits, or ½ a pint of beer

How much exercise do you do?*

Please provide the type of exercise and the number of times per week

Have you any specific nutritional requirements?

Yes

Do you have any allergies or sensitivities? YES (please specify)*

Yes (please specify below)

Allergy details*

WOMEN ONLY - Please let us know the date of your last cervical screening (smear) test

(if applicable)

Day

Month

Year

Carer information

A carer is a person who looks after a relative, friend, or a child with a physical or learning disability (this may include a mental health problem, long-term illness, or frailty). This definition does not include those who are paid carers.

Are you a carer or a young carer?*

Yes

Do you have a carer yourself?*

Yes

If yes, please give your carer’s name and emergency contact details below*

Do you have a social worker?*

Yes

If yes, please provide the name and contact details*

Looked after child/Child in care

A child who has been in the care of their local authority for more than 24 hours is known as a looked after child/child in care.

Are you a looked after child?*

Yes

Who are you living with?*

I am living with foster parents

I am living in a residential children's home

I am living in residential settings (e.g. school or secure unit)

If yes, please provide the name and contact details*

Protected characteristics (Equality Act 2010)

All the information given on this form will be kept in the strictest confidence, as part of your medical records.

Please only complete those sections you feel confident in completing or you feel are appropriate for the age of the patient. Please note that this information is helpful to our clinicians to allow them to provide you with the best quality and individualised service that we can offer.

At birth were you described as (please tick one option)

Male

Female

Intersex

Prefer not to say

Which of the following describes how you think of yourself? (please tick one option)

If you choose Other, please describe how you think of yourself in another way.

Male

Female

Other

Have you gone through any part of a process (including thoughts or actions) to change from the sex you were described as at birth to the gender you identify with, or do you intend to? (This could include changing your name, wearing different clothes taking hormones or having any gender reassignment surgery).

Yes

Continuing to think about these examples, which of the following options best applies to you? Please tick one option

I am thinking about going through this process

I am currently going through this process

I have already been through this process

I have been through this process, then changed back

None of the above

I prefer not to say

Which of the following describes how you think of yourself? (tick all that apply)

Trans man

Trans woman

Transsexual person

Gender variant person

Cross dressing person

Transvestite person

Intersex person

In another way

I prefer not to say

I think of myself in another way as described here

Ethnicity

What is your ethnic group?

Choose one option that best describes your ethnic group or background

I describe my ethnicity as

What is your religion/belief

Disability

You're disabled under the Equality Act 2010 if you have a physical or mental impairment that has a 'substantial' and 'long-term' negative effect on your ability to do normal daily activities.

Do you have a disability?

Yes

If yes, please describe any special help you require: (e.g. unable to manage stairs, easy-read information, sight/hearing assistance)

Are you considered housebound?

Yes

Please state any Sensory Impairment you have (e.g.. speech, hearing, sight):

Do you require correspondence to be in Braille, large print or Audio Tape?

Yes

Are you an ‘Assistance Dog’ User?

Yes

Please state any requirements you have to be able to access the Practice premises

Sexual orientation

Heterosexual or Straight

Gay or Lesbian

Bisexual

Do not know or not sure

Prefer not to say

Other

Patient Participation Group (PPG)

Our Patient Participation Group (PPG) is chaired by patients and provides the practice with feedback on how we improve our service delivery to meet the needs of our patients. We are an enthusiastic group and are always looking for new members to contribute.

Please tick here if you would like to be added to our PPG mailing list, to receive news and invitations to PPG meetings

Yes please (XaY0f)

New borns and under 5 immunisations

For new-born babies and children aged under 5 years, we require an up-to-date immunisation history. If you do not have this information please tick here*

I do not have this information

Summary Care Records (SCR)

The NHS Summary Care record is an electronic record of important information about your health. Access to SCR information means that care in other settings is safer, reducing the risk of prescribing errors. It also helps avoid delays to urgent care.

At a minimum, the SCR holds important information about;

current medication
allergies and details of any previous bad reactions to medicines
the name, address, date of birth and NHS number of the patient

Please confirm your preferences for your summary care records by ticking one box below:*

Consent given for medication, allergies, and adverse reactions ONLY (XaXbY)

Consent given for medication, allergies, adverse reactions, AND additional information e.g long-term conditions (XaXbZ)

To opt out from this practice sharing your information with a 3rd party e.g. research body, please tick the box opposite (XaXj6)

Please let us know which is your 1st main choice of contact*

Letter (XaR7B)

Text (XaQm0)

Pharmacy choice*

We are a paper-free surgery, as such our prescriptions are all sent electronically to a pharmacy of your choice. Please let us know which pharmacy you would like prescriptions to be sent to (this can be changed at a future date).

Consent*

By submitting your details you are consenting to providing this information for improving our services to you. The data you supply on this form will be securely stored on our website, which is hosted by a third party. We will retain this information on the website for no longer than 7 calendar days. Your contact details will not be sold or shared with a third party. I understand I can revoke this consent at anytime by contacting the practice. Our privacy policy can be viewed on this website.

I agree to the privacy policy.

Comments

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