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1 ADULT - FEB 15 Office use only Staff initials Date ID seen Welcome to Wokingham Medical Centre Thank you for completing this registration form. When registering in person at the surgery please supply two forms of identification, one of which should be a proof of address eg a recent utility bill. The other should be photographic ID eg a driving licence or passport. Please remember to sign the declaration. Registration forms can take up to 2 days to process. PLEASE PRINT CLEARLY Title Forename(s) Surname Date of birth Gender NHS number (if known) Address Town/Country of birth Home Telephone no. Postcode Work Telephone no. Mobile telephone no. Can we contact you by text? Address (Please print) Can we contact you by ? Previous address in UK Name and address of previous GP Ethnicity: Please enter the ethnic group which you consider you belong to I do not wish to answer this question Have you previously registered at this surgery? Out of area registration (if applicable, please tick) I understand that as I reside outside of the Practice Boundary I am not entitled to Home Visits Is English your main spoken language? If no what is your main spoken language? Do you need an interpreter? Are you a carer? (if yes, please give the name and date of birth of the person/people you care for if they are patients of ours) Does somebody care for you? (if yes, please give the name and date of birth of the person who cares for you if he or she is a patient of ours, or a name and telephone number if not)
2 Emergency contact Full Name: Relationship to patient: Have you any allergies or adverse drug reactions? If Yes, please state what you are allergic to, what happens and when you had your first reaction Contact number: Next of Kin If you are returning from abroad (previously resident in UK) Date of leaving: Date of returning: If you are from abroad (registering for the first time in the UK) Date you came to live in the UK: / / 2 forms of ID are required from the list below Utility Bill or Bank Statement with name and address National Insurance card Passport including Visa Weight (kg or st/lb) Do you smoke? No, I have never smoked No, I am an ex smoker Yes, I smoke Height (m or ft/in) Quit date if an ex-smoker: If a current smoker please enter number of cigarettes or g/oz of tobacco smoked per day: Smoking advice: Smoking can seriously damage your health. If you stop smoking you will dramatically reduce the risk of heart attacks, strokes and cancer. Giving up smoking is easier with professional support and we can even help easing withdrawl symptoms. We run smoking cessation clinics at the practice. To receive support to give up smoking please book an appointment at Reception. How much exercise do you do per week? Regular exercise at least 20 minutes 3 times a week will reduce blood pressure and reduce the risk of heart disease. How much, if any, alcohol do you drink per week? PLEASE CIRCLE ONE ANSWER PER QUESTION How often do you have a Never drink that contains alcohol? Monthly or less 2-4 times per month 2-3 times per week 4 times per week How many standard alcoholic drinks do you have on a typical day when you are drinking? How often do you have 6 or more standard drinks on one occasion? Never Less than monthly Monthly Weekly Daily or almost daily Small amounts of alcohol may be beneficial for you but too much can rapidly increase your risk of heart disease and high blood pressure.
3 Adult female patients only Have you had a hysterectomy? If yes, give date & specify what type if you know. When was your last cervical smear? Was it done: By your previous GP Family planning clinic YES / NO Do you still have your ovaries? YES / NO Date: What was the result: Suggested recall: Immunisation History (Please list any immunisations / vaccinations you have had including dates) Have you ever suffered from: Date of diagnosis Hypertension (high blood pressure) COPD/ emphysema / chronic bronchitis Asthma Diabetes Coronary heart disease/heart attack/angina
4 Epilepsy Thyroid problems Depression Other mental health problems Other physical health problems Operations (please list and include relevant dates) Are you on any regular or repeat medication including inhalers,regular creams or ointments, contraception pills or injections? Please list details were possible. Do you use Electronic Prescribing Service? If yes, which is your preferred pharmacy? Do you have any additional needs? (eg. Learning disabilities) If yes, please specify Are you interested in joining our Patient Participation Group? (If yes, please ensure you include your address)
5 What happens to my information? Personal and medical information about patients registered at this Practice are stored electronically and in paper form. Some of the information will be sent to hospital consultants and other health professionals to whom you are referred by your GP in order to provide continued health care and obtain treatment for you. We sometimes use accredited suppliers for our communication with you, for example when we send recall letters for medication reviews or invitations to our flu clinics. All suppliers we use are checked carefully to ensure they comply with strict confidentiality protocols. To ensure the security of all patient information all staff who have access to your details and medical records are covered by confidentially clauses in their employment contracts and the Data Protection Act and Freedom of Information Act. Our guiding principle is that we hold your records in strict confidence. I certify that the information I have provided is correct and consent to my personal and medical information being used as stated above. Your signature: Date: NHS Organ Donor registration I want to register on the NHS Organ Donor Register as someone whose organs/tissue may be used for transplantation after your death. please tick boxes that apply: Any of my organs and tissue or Kidneys Heart Liver Corneas Lungs Pancreas Any part of my body Signature confirming consent to Organ/Tissue donation Date / / NHS Blood Donor registration If you would like to join the NHS Blood Donor Register as someone who may be contacted and would be prepared to donate blood, please visit their website: or call direct on THANK YOU FOR YOUR HELP IN COMPLETING THIS FORM Office use only Registered by (initials) EMIS No: Usual DR: Lifestyle coded:
6 Summary Care Records Summary Care Records (SCR) contain key information about medicines you are taking, allergies you suffer from and any bad reactions to medicines you have had in the past. Giving healthcare staff access to this information can prevent mistakes being made when caring for you in an emergency or when the surgery is closed. Your SCR will include your name, address, date of birth and your unique NHS number to help identify you correctly. Our GP Practice is supporting Summary Care Records and as a patient you have a choice: Yes, I would like a Summary Care Record. If you want a record you do not need to do anything further, one will be created for you when processing this registration form. If you have opted out of having a record in the past but have now changed your mind, let us know so one can be created for you. No, I do not want a Summary Care Record. PLEASE COMPLETE THE ATTACHED OPT OUT FORM. If you do not want a record, you will need to fill in a Summary Care Record opt out form and hand it in to the surgery. Opt out forms are available from reception or via the website You are free to change your decision at any time by informing us at the practice. Children will automatically have a Summary Care Record made for them. If an Opt out form is completed for a child the GP will consider the request.
7 Information to be withheld from the Summary Care Record If you DO NOT want a Summary Care Record please fill out the form and send it to your GP practice A. Please complete in BLOCK CAPITALS Title... Surname / Familyname... Forename(s)... Address Postcode... Phone No... Date of birth... NHS Number (if known)... Signature... B. If you are filling out this form on behalf of another person or a child, their GP practice will consider this request. Please ensure you fill out their details in section A and your details in section B Your name... Your signature... Relationship to patient... Date... What does it mean if I DO NOT have a Summary Care Record? NHS healthcare staff caring for you may not be aware of your current medications, allergies you suffer from and any bad reactions to medicines you have had, in order to treat you safely in an emergency. Your records will stay as they are now with information being shared by letter, , fax or phone. If you have any questions, or if you want to discuss your choices, please contact your GP practice. Your emergency care summary Actioned by practice: yes / no Date... FOR NHS USE ONLY CONFIDENTIAL
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