New Patient Registration Form (GMS1) V2

Fields marked "REQUIRED" are compulsory. 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. You are required to present in person to sign your registration form and provide proof of your address. Sending this form does NOT guarantee or even imply that you will be accepted onto the practice register.

Last Updated: 03/06/2021

Patients Details















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




If you are from abroad



Service Families and Military Veterans

As a practice, we fully support the Armed Forces Covenant. We can only do this if we know our patients connections to the Armed Forces. Please tick the below boxes that apply to you:


About You











Contacting you

We will use your contact details to send reminders about appointments, reviews and other services which may be of benefit in your medical care






Summary Care Record

Summary Care Record (SCR) If you decide to have a SCR, it will contain important information about any medicines you are taking, allergies you suffer from and any bad reactions to medicines that you have had it will also include basic information about your current diagnoses. Giving healthcare staff access to this information can prevent mistakes being made when caring for you in an emergency or when your GP practice is closed. Your Summary Care Record will also include your name, address, date of birth and your unique NHS Number to help identify you correctly. If you and your GP decide to include more information it can be added, but only with your express permission. For more information: Phone 0300 123 3020 or visit www.nhscarerecords.nhs.uk


Electronic Prescribing Service (EPS)

The EPS allows prescribers – such as GPs and practice nurses to send prescriptions electronically to a dispenser (such as a pharmacy) of the patient’s choice. This makes the prescribing and dispensing process more efficient and convenient for patients and staff. The NHS aim that by 2020 they will hopefully be paper free or a paper-lite service. To help achieve this, we would encourage all patients to opt for electronic prescribing.



Donation wishes

If you live in England, Wales or Jersey, are not in a group excluded from opt out legislation and you have not registered an organ donation decision, it will be considered that you agree to be an organ donor. This is known as deemed consent. If you do not want to donate your organs then you should register your decision to refuse to donate. Remember to speak to your family and loved ones about your decision.


Resuscitation wishes and Power of Attorney

If YES to either of the below questions, please supply details of who holds this and where (and supply a copy for your medical notes). Details



Smoking Status

Stopping smoking is not easy but it can be done, and there is now a comprehensive, NHS Smoking Cessation Service offering support and help to smokers wanting to stop, with cessation aids available on NHS prescription. If you would like help and advice on how to give up smoking, please contact https://www.quit4life.nhs.uk/ or ask at reception.





Non-Attendance of Appointments

There are increasing pressures upon all doctors and nurses to reduce waiting times and increase patient access. Sadly, a number of appointments are wasted each week due to patients not giving us notice that they would not be attending appointments. In addition, nursing and administrative time is wasted where records and/or equipment needs advance preparation. We would appreciate it, if you know you cannot attend an appointment, that you cancel it as early as possible. We will continue to monitor missed appointments. Persistent failure to either cancel or attend may result in removal from our list. Zero Tolerance Our practice staff are here to help you. Our aim is to be as polite and helpful as possible to ALL patients. If you consider that you have been treated unfairly or inappropriately please ask the reception team to contact a member of the management team who will be happy to address your concerns. However, shouting and swearing at practice staff will NOT be tolerated under ANY circumstances and patients who are abusive may be removed from the practice list. Please help us to help you


Height/Weight



Disabilities/Accessible Information Standards

As a practice we want to make sure that we give you information that is clear to you. For that reason we would like to know if you have any communication needs.







Family History and past medical history



Allergies


For female patients only