|
|
|
|
PLEASE USE "under -16 registration link" for children PLEASE NOTE INFORMATION ABOUT SHARED SUMMARY CARE RECORD Goodwood Court Medical Centre & The Eaton Centre New Patient Registration Form Thank you for asking to register at our medical practice. Before we can consider your registration, we need to ask you to complete this form as fully as possible. Incomplete forms may not be accepted. To prevent fraudulent use of NHS resources, we must ask you to provide the following original documentation when you register and copies will be taken of these documents for record purposes. This applies to ALL applicants 1: Photographic identification (Passport, Home Office Registration Card, Driving Licence or ID card which has an up-to-date photograph) 2: Proof of address (A utility bill, bank statement, lease document or similar which confirms your residence) 3: Proof of stay in the UK – letter from employer, college, letting agent, or similar – indicating that your intended stay in the UK is 6 months or more from the date of entry. 4: If from countries other than the EU: current Visa or proof of eligibility to remain in the UK
Your Surname (Family Name)- as appears on your passport ALL your Forenames (Given Names) Your title if other, please specify: Your date of birthyear: Your sex: Your address in HOVE / BRIGHTON: Flat : Number of Road: Name of Road: Post Code: How can we contact you? The more options you give us, the better chance we have of informing you about matters appropriate to your medical care: Your landline telephone number Your mobile telephone number Do you accept text messages:Your work telephone number Your email address: Your ethnic origin:specify if necessary: Your place & country of Birth: Your MAIN LANGUAGE: If previously registered in the UK, the address at which you were last living: And the name of the GP/ practice your were registered with at that time: YOUR NHS Number if known (10 digits) Your SERVICE number if you have transferred from UK armed services & where were you last based? If not previously registered in UK, the date you came to the UKyear: Have you previously been registered with our practice?
Your ethnic origin:specify if necessary: Would you also like us to pass your details to Dr Loubser, Dental Practitioner, who practices at Goodwood Court? Her receptionist will contact you to discuss your needs
Thank you for completing the questions above. You should print a copy and submit it in person to us at Goodwood Court Medical Centre. You will need to provide evidence of identity (passport/photo id) and evidence of residence in the area. Those from abroad will need proof of entitlement to remain in the UK for at least six months. Please now SIGN this form as confirmation of your wish to register with our practice.
Signed: ________________________________________- date: ___________________ ++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++ Now we need to ask you some information about your medical and personal history. All information is subject to "Caldicott guidelines" - more information is available on our notice board and in our practice policies about what it entered onto our computerised clinical database. This information will be used solely to ensure that any clinician caring for you at the practice is aware of various aspects of your medical history. Dr Nigel Higson, Caldicott Guardian, Goodwood Court Medical Centre
Your Occupation Any significant childhood illnesses - please list those you recall Did you have routine childhood vaccination as far as you are aware? What vaccinations do you recall having been given in the last few years? Please list any medical problems that have been diagnosed or that have affected you in the past - together with approximate dates and whether you are still affected by them Problem approximate date of onset Still bothering you? Any medications you take for this condition
Have you had any surgical operations? If so , please list below Approximate date of surgery
Have you ever had a BLOOD TRANSFUSION? Why was it done?Are you allergic to any drug or medical dressing: If so, what drug and what happened? What is your approximate height? and your approximate weight?How many times a week do you undertake exercise of 20 minutes or more? If you drink alcohol most weeks, how much on average in a week? if more than 30 units, please specify: The following 4questions are designed to screen the population to find those who might need help with their alcohol... 1:How often do you have EIGHT or more units (SIX for women) on one occasion (one unit is half a pint of beer or small glass of wine) 2:How often during the last year have you been unable to remember what happened the night before because you had been drinking? 3:How often during the last year have you failed to do what was normally expected of you because of drinking ?4:In the last year has a relative or friend, or a doctor or healthworker been concerned about your drinking or suggested you cut down? If you drink alcohol most weeks, how much on average in a week? if more than 30 units, please specify: Would you like help to change your drinking habits? Do you smoke / have you previously smoked? more info:Would you like help to change your smoking habits? Do you currently use any illegal or "recreational" drugs? if so, have you ever given yourself drugs with a needle? If this is the case, we advise you have a check for blood borne virus infection (hepatitis B or hepatitis C or HiV) Do you live alone? Do you have frequent unexplained falls? Do you have visual or hearing loss?Do you have an Advance Directive or Living Will? if so, perhaps you would let us have a copy for your records.Are you a carer for anyone else? if so, please would you let us have their details:For women: when did you last have a Cervical Smear ("pap smear") was it normal?
FAMILY HISTORY - some illnesses or conditions are passed from generation to generation or increase risks of other family members developing the condition... please would you complete the following table as best you can Any significant medical history (heart disease, cancer, stroke, diabetes, etc) in Your father Your mother Your siblings Your father's father Your father's mother Your mother's father Your mother's mother Anything else you would like to mention when registering:
PLEASE NOW PRINT THIS FORM BY USING THE PRINT BUTTON ON YOUR BROWSER
|
|
Send mail to
nigel.higson@nhs.net with
questions or comments about this web site.
|
