New Patient Registration Form

This form is for patients who wish to register with us.

You must complete the form in one sitting, so please set aside at least 15 minutes to do this.

This is an "intelligent" form, which may add or remove questions based on your answers, for example if we need more details, or if a question is not applicable to you.

Please read all the information carefully, as you will be asked to decide on your consent to a number of different questions.

If you need help navigating the form, or you would prefer to complete a paper copy, please call the Practice.

Page {{ paginatorProps.current }} of {{ paginatorProps.total }} ({{ paginatorProps.percentage }}% completed)

Your personal information

Sex at birth: *

Gender: *

NHS recording only allow previous options

Have you been registered in the UK before?: *

Please provide a UK Telephone number (landline or mobile) so we can book Telephone Consultations with the Doctors or Nurses.

Are you a Veteran? :

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

If you are from abroad

If you have ever been 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:

Ethnicity

Please tick one box that best describes your ethnic group or background from the following options: *

White Ethnic group or background:

Mixed Ethnic group or background:

Asian Ethnic group or background:

Black Ethnic group or background:

Other ethnic group:

Summary Care Record

Consent options for Summary Care Record (not mandatory):

If you require any more information, please visit http://digital.nhs.uk/scr/patients or phone NHS Digital on 0300 303 5678 or speak to your GP practice.

Sharing your health record

Sharing OUT - I would like my health record at Bridge Street Medical Centre to be shared with other healthcare services providing care for me.: *

Note: You can request individual entries in your record to be marked as “Private”. These are not shared with the rest of your record even if you choose to share OUT.

Sharing IN - I would like Bridge Street Medical Centre to be able to view information in my health record that has been recorded by other healthcare services.: *

Please contact the Patient Experience Team on 0800 273 2535 or capccg.pet@nhs.net if you have any queries.

Your medical history

Do you currently smoke?: *

If you smoke, we would advise you to stop and welcome you to make an appointment with our team for smoking cessation advice, or visit www.nhs.uk/smokefree

If you have come from abroad please bring in a copy of your medical and vaccination record.

Have you ever had a cervical / pap smear?:

Have you had a hysterectomy?:

Are you currently using the coil?:

Alcohol Questionnaire

How often do you have a drink containing alcohol?: *

How many units of alcohol do you drink on a typical day when you are drinking?: *

How often do you have six or more units of alcohol on one occasion?: *

How often during the last year have you found that you were not able to stop drinking once you had started?: *

How often during the last year have you failed to do what was normally expected from you because of drinking?: *

How often during the last year have you needed a first drink in the morning to get yourself going after a heavy drinking session?: *

How often during the last year have you had a feeling of guilt or remorse after drinking?: *

How often during the last year have you been unable to remember what happened the night before because you had been drinking?: *

Have you or someone else been injured as a result of your drinking?: *

Has a relative/friend/ health worker been concerned about your drinking or suggested you cut down?: *

If your total score for questions 1 to 10 is 8+, we would like to invite you to make an appointment with our practice nurse to discuss this further. You can also visit: www.units.nhs.uk/

Electronic Prescription Service - Patient Nomination Request

Nominated pharmacy:

Next of kin

Signature

Who is signing this form?: *

Proof of identity and proof of address

Only following file extensions are allowed: jpg, jpeg, png, webp, pdf, doc, docx, pptx

Privacy Consent

This form collects personal and medical information about you. We use this information to allow the practice team to contact you. Please read our Privacy Policy to discover how we protect and manage your submitted data.

Processing

There appears to be a problem loading the form, please refresh the page.
If the error persists please contact us.

Strictly necessary cookies

Optional cookies

New Patient Registration Form

This form is for patients who wish to register with us.

Privacy Consent

CONTACT DETAILS

PRACTICE POLICIES

RESEARCH