Are you completing this form for a child under 16 years old?
Required
No
Yes
Title
Required
First name
Required
Last name
Required
Date of Birth
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Europe/London
NHS number (if known)
Sex at birth
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Male
Female
Gender
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Male Female Other
Religion
** None No religion Christianity Buddhism Hinduism Islam Judaism Sikhism Other I do not wish to state
Ethnicity
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Arab Asian or Asian British - Bangladeshi Asian or Asian British - Indian Asian or Asian British - Other Asian or Asian British - Pakistani Black or Black African Black or Black British Black or Black Caribbean Black or Black Other Gypsy or Irish Traveller Mixed - Other Mixed - White and Asian Mixed - White and Black African Mixed - White and Black British Mixed - White and Black Caribbean White - British White - Caucasian White - Irish White - Other Other - Chinese I do not wish to state
What is your main spoken language?
Required
Do you need an interpreter?
Yes
No
Do you use any of the following?
Sign Language
Lip Reading
Hearing aid
Your address
Have you lived at your current home address for more than 3 years?
Yes
No
If you have not lived at your current address for more than three years, please provide your previous home address
Phone number
Required
Email address
Have you previously been registered with an NHS GP?
Yes
No
Please provide the name and address of your previous GP
Were you born in the UK?
Required
Yes
No
If you were not born in the UK, when did you enter the UK?
What country were you born in?
Required
Place of birth (e.g town or city)
Required
Have your previously served in the armed forces?
Next of Kin details
Please provide your next of kin's full name, contact number and their relationship to you below.
Your information
We would like to send you text messages to your registered mobile about your healthcare. This may include things like appointment reminders and test results. Is this OK?
Required
Yes
No
Would you like us to send you appropriate emails from the surgery?
Required
Yes
No
Summary Care Record
A summary care record (SCR) is an electronic summary of key health information. It will hold limited essential information derived initially from your GP record. This will include medication, adverse reactions and allergies. If you wish to know more information regarding the system and the benefits please ask reception. Alternatively, visit the website: www.nhscarerecords.nhs.uk or call 0845 603 8510
Would you like to opt in to the Summary Care Record?
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Opt in
Opt out
Are you happy for us to share your full medical records electronically with other services involved in your care?
Required
Yes
No
Patient signature
Required