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. Please complete the registration form for all family members.

Name(Required)

Prefix First Middle Last

Gender(Required)

Date of Birth(Required)

NHS Number if known

Mobile Telephone Number

Home Telephone Number

Email Address

Home Address(Required)

House/Flat Number/Name First Line of Address Town County Postcode

PREVIOUS Home Address(Required)

House/Flat Number/Name First Line of Address Town County Postcode

Town of Birth(Required)

Country of Birth(Required)

PREVIOUS GP Surgery

House/Flat Number/Name GP Surgery Name First Line of Address Town County Postcode

Please select any or all that apply

Asylim Seeker

Student

Refugee

None of the above

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?

Yes

Date you first came to the UK

Only required is you answered yes to the above question

Are you returning or arriving in the UK from abroad

Yes

Date of Return to UK

Only required is you answered yes to the previous question is yes

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?

Yes

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

Yes

Armed Forces Role

Regular

Reservist

Veteran

Family Member Armed Forces Role

Spouse

Civil Partner

Child

Service Personal Number

Enlistment Date

Discharge Date

Address prior to enlisting

House/Flat Number/Name First Line of Address Town County Postcode

Patient Signature(Required)

Typing you name will count as a signature

Relationship to the Patient

Child's Education Setting

Please complete the name of the education setting for children aged 18 and under only.

Next of Kin Details

Full Name

Next of Kin Details

Address

Next of Kin Details

Relationship

Next of Kin Details

Phone Number

Are any other family members registered at the Practice

Yes

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?

Are you cared for by someone?

Do you care for someone?

Emergency Contact Details

Required only if not Next of Kin

Emergency Contact Details

Same as Next of Kin

Someone Else

Emergency Contact Details if not next of Kin

Full Name

Emergency Contact Details

Phone Number

Emergency Contact Details

Relationship

Emergency Contact Details

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

African

Caribbean

Any other Black background

Mixed ethnic background

Asian and White

Black African and White

Black Caribbean and White

Any other mixed ethnic background

Asian

Bangladeshi

Indian

Pakistani

Any other Asian background

Chinese

White

Any other ethnic background

Main Language Spoken

Do you need an interpreter?

Yes

Religion

Social Services

Have your previously or currently receiving support from social care?

Yes

Health Information

Height

Centimetres

Weight

Kilograms

Smoking

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

Are or have you ever smoked?

Date stopped smoking?

How many per day

Type of smoking method

Alcohol

The Fast Alcohol Screening Test (FAST)

Alcohol consumption screening test declined

Yes

How often do you have a drink containing alcohol? *

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?

Yes on one occassion

Yes on more than one occassion

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.

Date of reading

Time of Reading

Systolic (top)

Please enter a number from 50 to 200.

Diastolic (bottom)

Please enter a number from 50 to 200.

Medical History

Do you suffer with any of the following medical conditions? *

Do you have any allergies ?

Have you ever had an allergic reaction ?

Please provide details of allergies

Please provide details of allergic reactions

Do you have any disability, impairment or sensory loss ? *

Are you also taking medication prescribed by hospital, outside the GP?

Yes

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?

Yes

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?

Housebound

Under the case of a hospital specialist

Preferred Pharmacy

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

Preferred Pharmacy Name *

Location

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.

File

Max. file size: 10 MB.

New Patient Registration Checklist

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)

I confirm to have checked my postcode to be within the practice boundary

Form Completion(Required)

I have completed all section as required