Farnham Park Health Group

01252 723122

Please call after 11:00am for
all general enquiries

Please use askmyGP 8am to 3pm Monday to Friday. Between 3pm and 6.30pm please call the surgery if it is urgent
Please use askmyGP 8am to 3pm Monday to Friday. Between 3pm and 6.30pm please call the surgery if it is urgent.

New Patient Registration Form

New Patient Registration Form

The information you supply us will be used lawfully, in accordance with the Data Protection Act 2018. The Data Protection Act 2018 gives you the right to know what information is held about you, and sets out rules to make sure that this information is handled properly.
Name(Required)
DD slash MM slash YYYY
House/Flat Number/Name First Line of Address Town County Postcode
House/Flat Number/Name First Line of Address Town County Postcode
House/Flat Number/Name GP Surgery Name First Line of Address Town County Postcode
Please select any or all that apply

European Economic Area (EEA) Country

European Economic Area (EEA) Country
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?
Only required is you answered yes to the above question
DD slash MM slash YYYY
Are you returning or arriving in the UK from abroad
Only required is you answered yes to the previous question is yes
DD slash MM slash YYYY

Armed Forces Personnel

Complete only if applicable These questions are optional and your answers will not affect your entitlement to register or receive services from the NHS but improve access to some of NHS priority and service charities services.
Armed Forces
Where you ever registered with an Armed Forces GP?
Registered with Ministry of Defence GP
Please indicate if you were registered with a GP whilst in the UK Armed Forces serving in the UK or Oversea
Armed Forces Role
Family Member Armed Forces Role
House/Flat Number/Name First Line of Address Town County Postcode
Typing you name will count as a signature
Please complete the name of the education setting for children aged 18 and under only.

Next of Kin Details

Full Name
Address
Relationship
Phone Number
Are any other family members registered at the Practice

Carers

It’s important that everyone who works here at Farnham Park Health Group knows you are a carer so that we can offer you help and support if you need it. Anyone who looks after a friend or family member who cannot manage without them, and is unpaid, can register. This includes carers under the age of 18.
Are you a carer or cared for?

Emergency Contact Details

Required only if not Next of Kin
Emergency Contact Details
Full Name
Phone Number
Relationship
Address

Patient Participation Group

We have a patient participation group who meet with the practice on a quarterly basis. This group provides an effective way of patients and the surgery working together to improve services and to promote health and improved quality of care. If you are interested in joining the group, please complete the form online www.farnhamgps.com/patient-group/join-ppg/

Patient Ethnic Origin Questionnaire

In compliance with the Race Relations (Amendment) Act 2000 and its Race Equality Scheme any new patient registrations are requested to complete this form. Which of the following best describes your ethnic background? *
British or Mixed British
Black
Mixed ethnic background
Asian
Do you need an interpreter?

Social Services

Have your previously or currently receiving support from social care?

Health Information

Centimetres
Kilograms

Smoking

If you would like help to stop smoking, please visit NHS Smokefree. https://www.nhs.uk/better-health/quit-smoking/
DD slash MM slash YYYY

Alcohol

The Fast Alcohol Screening Test (FAST)
Alcohol consumption screening test declined
How often do you have 8 or more drinks (for a man) / 6 or more drinks (for a woman) on one occasion?
How often during the last year have you been unable to remember what happened the night before because you had
How often during the last year have you failed to do what is expected of you because of your drinking?
In the last year has a relative or friend, or a doctor or health worker, been concerned about your drinking or suggested that you cut down?

Blood Pressure

As part of our new patient health screening program we require a blood pressure recording for all new patients. You can measure the reading at home if you have a blood pressure machine or at a local pharmacy. Alternatively, if you have your latest blood pressure readings, please enter them here.
DD slash MM slash YYYY
Time of Reading
:
Please enter a number from 50 to 200.
Please enter a number from 50 to 200.

Medical History

Do you suffer with any of the following medical conditions? *
Do you have any disability, impairment or sensory loss ? *

Are you also taking medication prescribed by hospital, outside the GP?
If you have medications please ensure you book a routine appointment so your repeat prescription(s) can be set up BEFORE they are due - there is a lead time to routine appointments being available.
Are you taking any medication/injections currently?
If you have medications please ensure you book a routine appointment so your repeat prescription(s) can be set up BEFORE they are due - there is a lead time to routine appointments being available.

Family History

Have your parents, brothers or sisters suffered from any of the following medical conditions? *

Additional Details

Are you?

Preferred Pharmacy

Please specify name and location of pharmacy all prescriptions will be sent electronically to your nominated chemist.

Proof of ID and Address

Please provide one proof of identify (ID) and one proof of address (POA) from the approved list on the New Patient Registration Page.
Max. file size: 10 MB.

New Patient Registration Checklist

Consent to receive texts and e-mails from the surgery

Online Access

We are asking all new patients who register with us to download the NHS App to enable you to: Renew repeat prescriptions. Book and manage appointments. Securely access your medical records. Check your symptoms, get instant advice, and more Complete the online access application www.farnhamgps.com/patient-info/online-access-16
Practice Boundary(Required)
Form Completion(Required)