New Patient Registration

Please complete this confidential questionnaire.

If you are newly arrived in this country, please bring your passport to confirm your date of birth and entitlement to NHS treatment.

Please complete a separate form for each family member to be registered.

New Patient Registration - Rowhedge

New Patient Registration - Rowhedge

Patient Details

Please use date format DD/MM/YYYY
All correspondence will go to this address.
Is English your main or first language?

Next of Kin

Your Medical Background

Please give dates in DD/MM/YYYY format.
Please give dates in DD/MM/YYYY format.
including dose and frequency
Please bring a list or print-out of your current medications with you to your new patient check.
Are you able to administer your own medicines? *
(e.g. swallowing, opening containers)
Are there any serious diseases that affect your parents, brothers or sisters? Please check all that apply. *
What immunisations have you had? Please check all that apply.

Lifestyle

Smoking

Are you currently a smoker?
Have you ever been a smoker?

If you would like to stop smoking, please ask a receptionist for information about local smoking cessation services.

Exercise

Alcohol Consumption

This is one unit of alcohol:

Amount of different types of drink representing one unit of alcohol

And each one of these, is more than one unit:

Amount of different types of drink representing more than one unit of alcohol
These questions are about your use of alcohol during the past 12 months.
How often do you have a drink containing alcohol? *
How many alcohol units do you have on a typical day when you are drinking? *
How often do you have 6 or more units (if female), or 8 or more units (if male) on one occasion? *

Specific Needs

Please detail below any specific needs you have so the Practice can ensure they are identified and accommodated by taking the appropriate action.
Do you have a sensory impairment?
Please select a sensory impairment:
Do you require the help of an translator/interpreter?

Veterans

Are you a Service Veteran? *
Which service did you serve in? *
Please use format DD/MM/YYYY
Please use format DD/MM/YYYY

Carers

Person Cared For Details

Carer Details

Please sign below if you wish us to disclose information about your health to your Carer.

Living Will and Power of Attorney

Do you have a 'Living Will'? *
Please bring a written copy of your Living Will to your New Patient Check.
Have you nominated someone to speak on your behalf (e.g. a person who has Power of Attorney)? *
Please give their details.

Women Only

Please use date format DD/MM/YYYY
Please use date format DD/MM/YYYY

Virtual Patient Participation Group

The Practice is committed to improving the services we provide to our patients.
To do this, it is vital that we hear from people about their experiences, views, and ideas for making services better.
By expressing your interest, you will be helping us to plan ways of involving patients that suit you.
It will also mean we can keep you informed of opportunities to give your views and up to date with developments within the Practice.
If you are interested in getting involved, please tick the box below and we will arrange for your e mail details to be added to the Virtual Patient Participation Group.
*

Summary Care Record

The summary care record (SCR) is a summary of a patient’s sensitivities & medication uploaded to the NHS Spine so that it can be accessed by any legitimate carer. Regardless of the computer system they use.

The circumstances when this is beneficial include when a patient is seen at hospital or Out of Hours unit or when a temporary resident is seen at a GP practice.

Do you consent to SCR on your medical records? *