Register patients over the age of 5

Please complete this as fully as possible to allow us to register you quickly. If you need to register a child under 6 years of age please visit this page. You cannot register children under 6 using this online form.

Patient's details

Title(Required)

NHS Number

Get help to find your NHS number online

Name(Required)

First Names Surname

Previous surname (if applicable)

Date of Birth(Required)

Male/Female(Required)

Male

Female

Current home address (inc. flat number if appropriate)*(Required)

Current postcode*(Required)

Mobile Telephone*(Required)

If you don't have a mobile please provide another contact telephone number here.

Alternative Telephone

Work Telephone

Email*(Required)

I consent to be contacted by email at this address*

Enter Email Confirm Email

* It is your responsibility to keep us updated with any changes to your telephone number, email & postal address. We may contact you with appointment details, test results, health campaigns or Patient Participation Group details If you do not consent to being contacted by SMS or Email, please tick here:

NOT by Email

NOT by SMS text

Your Town and Country of birth(Required)

Have you returned to the UK from abroad?(Required)

Yes

Please give the date you left the UK

Please give the date of your return to the UK

Are you registering with the NHS for the first time in the UK?(Required)

Yes

Please give the date you came to the UK

If this registration is for a child, what school do they go to? Full school address is required.

Who lives in your household? Adults and children please tell us their full names and relationship to you.(Required)

If you live alone please tell us in this box.

Non-UK European Health Insurance Card (EHIC), Provisional Replacement Certificate (PRC) details and S1 forms

You only need to complete this section if you live in another EEA country, or have moved to the UK to study or retire, or if you live in the UK but work in another EEA member state. Do not complete this section if you have an EHIC issued by the UK.

I live in another EEA country, or I have moved to the UK to study or retire, or I live in the UK but work in another EEA member state.

Yes

Do you have a non-UK EHIC or PRC?

If you select yes please complete the additional details from your EHIC card that will appear below.

Yes

If yes, please enter details from your EHIC or PRC below:

3: Name(Required)

Country Code(Required)

4: Given Names(Required)

5: Date of Birth(Required)

6: Personal Identification Number(Required)

7: Identification number of the institution(Required)

8: Identification number of the card(Required)

9: Expiry Date

PRC validity period (a) From:

PRC validity period (b) To:

Supplementary questions

These questions and the patient declaration are optional and your answers will not affect your entitlement to register or receive services from your GP.

Are you ordinarily resident in the UK(Required)

Yes

PATIENT DECLARATION for all patients who are not ordinarily resident in the UK

Anybody in England can register with a GP practice and receive free medical care from that practice. However, if you are not ‘ordinarily resident’ in the UK you may have to pay for NHS treatment outside of the GP practice. Being ordinarily resident broadly means living lawfully in the UK on a properly settled basis for the time being. In most cases, nationals of countries outside the European Economic Area must also have the status of ‘indefinite leave to remain’ in the UK.

Some services, such as diagnostic tests of suspected infectious diseases and any treatment of those diseases are free of charge to all people, while some groups who are not ordinarily resident here are exempt from all treatment charges.

More information on ordinary residence, exemptions and paying for NHS services can be found in the Visitor and Migrant patient leaflet, available from your GP practice.

You may be asked to provide proof of entitlement in order to receive free NHS treatment outside of the GP practice, otherwise you may be charged for your treatment. Even if you have to pay for a service, you will always be provided with any immediately necessary or urgent treatment, regardless of advance payment.

The information you give on this form will be used to assist in identifying your chargeable status, and may be shared, including with NHS secondary care organisations (e.g. hospitals) and NHS Digital, for the purposes of validation, invoicing and cost recovery. You may be contacted on behalf of the NHS to confirm any details you have provided.

Please select one of the following options(Required)

I understand that I may need to pay for NHS treatment outside of the GP practice

I understand I have a valid exemption from paying for NHS treatment outside of the GP practice. This includes for example, an EHIC, or payment of the Immigration Health Charge (“the Surcharge”), when accompanied by a valid visa. I can provide documents to support this when requested

I do not know my chargeable status

I declare that the information I give on this form is correct and complete. I understand that if it is not correct, appropriate action may be taken against me.

A parent/guardian should complete the form on behalf of a child under 16.

I agree to the statement above

S1 Form

Please tick if you have an S1 (e.g. you are retiring to the UK or you have been posted here by your employer for work or you live in the UK but work in another EEA member state).

Please give your S1 form to the practice staff. How will your EHIC/PRC/S1 data be used? By using your EHIC or PRC for NHS treatment costs your EHIC or PRC data and GP appointment data will be shared with NHS secondary care (hospitals) and NHS Digital solely for the purposes of cost recovery. Your clinical data will not be shared in the cost recovery process. Your EHIC, PRC or S1 information will be shared with The Department for Work and Pensions for the purpose of recovering your NHS costs from your home country.

Yes I have an S1 form

Your next of kin

Name, address and telephone number of next of kin and their relationship to you (Please ensure your Next of Kin have consented to have these details stored on your medical record)

Next of kin name(Required)

First Last

Next of kin address(Required)

Relationship to you:(Required)

Contact number:(Required)

Emergency Contact Details

Name, address and telephone number of people we could contact in an emergency if different from Next of Kin (Please ensure your emergency contact person have consented to have these details stored on your medical record)

Other details

Please confirm who else lives at your current home address(Required)

Please provide their full name, date of birth and their relationship to you.

Please enter your previous address(Required)

Please help us trace your previous medical records by providing this information.

Previous postcode(Required)

Previous GP name and address(Required)

Please help us trace your previous medical records by providing this information.

Were you ever registered with an Armed Forces GP?

These questions are optional and your answers will not affect your entitlement to register or receive services from the NHS but may improve access to some NHS priority and service charities services.

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

Regular

Reservist

Veteran

Family Member (Spouse, Civil Partner, Service Child)

Address before enlisting

Postcode

Service or Personnel number

Enlistment date

Discharge date (if applicable)

About you

Your Ethnicity(Required)

Your Religion(Required)

Your Housing(Required)

Your Employment(Required)

Communication needs

What is your first language?(Required)

Do you need an interpreter?(Required)

Yes

Language of interpreter

Additional Needs

Are you registered disabled? (If yes, please give details)

Do you have any specific communication needs? By leaving this section blank we will not record the need for alternative communication methods in your record.

Do you have a learning disability?(Required)

If yes, please request a Learning Disability Tool form

Yes

Do you have a social worker?(Required)

Yes

Carers

A Carer is someone, who, without payment, provides help and support to a partner, child, relative, friend or neighbour, who could not manage without their help. This could be due to being elderly, physical or mental illness, addiction or disability. We would be grateful if you could complete the following questions for the Practice Carer’s Register. The register enables the practice to proactively manage carer’s needs with the practice and to consider the provision of services to carers. The practice will also ensure that all patients who are carers are informed of and supported in joining the local carer’s link.

Are you a carer?(Required)

Yes - Informal/Unpaid carer

Yes - Occupational/Paid Carer

Name of the person you care for:

First Last

What is your relationship with the person you care for?

DOB of the person you care for:

Address of the person you care for:

Telephone number of the person you care for:

NHS number of the person you care for:

Are you being cared for?(Required)

Yes

Name of your carer:

First Last

What is your relationship with your carer?

DOB of your carer:

Address of your carer:

Telephone number of your carer:

NHS number of your carer:

If you consent to your Carer being informed of any medical information about you which is held at the practice, please check the box below; if NOT leave blank

I am happy for my carer to be informed of any medical information about me which is held by the practice.

Medical information

Please list any serious illnesses/operations/accidents/disabilities (and for women any pregnancy related problems) and the year they took place

Have you suffered from any of the following conditions?(Required)

Please state the type of cancer

Please let us know which mental health problem you suffer from or have received treatment for in the past

Depression

OCD

Anxiety

Bipolar disorder

Please state the year when you were first diagnosed (or approximate date)

Do you have any other mental health problems? If yes, please state these below

ALLERGIES: Please list any allergies or sensitivities you have including drug allergies below(Required)

Please enter 'N/A' if you have no allergies to report

Do you regularly use any drugs, supplements or medicines that have not been prescribed by a doctor? Please give details below:

Immunisation History – This is required information for children. If its your child please bring the baby books or proof of the immunisations. Please give the dates you last had the following immunisations:(Required)

Tetanus, Diptheria, Whooping Cough. Polio, Meningitis, Measles, Mumps, Rubella, BCG. Enter the vaccination/immunisation name and date you last had it. Click the + symbol to add more rows. Please put "none" in both boxes if you do not have this information and you are over 18.

Immunisation

Date

Any other conditions, operations or hospital admission details:

If you are currently under the care of a Hospital or Consultant outside our area, please tell us here:

Family history

Please record any significant family history of close relatives with medical problems and confirm which relative e.g. mother, father, brother, sister, grandparent

Please give any details if you have ticked any of the above

Current medication

Please check and include as much information about your current medication below. Please give us your previous repeat medication list if possible. A medication review appointment may be needed(Required)

Please enter 'N/A' if taking no medication

Alcohol consumption - How many units of alcohol do you consume in a week?

Approximately - 1 drink = 1/2 pint of beer or 1 glass of wine or 1 single spirits. 1 unit of alcohol = 10cc of alcohol. So, a small glass (125cc) of 12% wine is 12.5 * 0.12 = 1.5 units. Find out more about alcohol units on the NHS website

How often do you have a drink containing alcohol?(Required)

How many units of alcohol do you drink on a typical day when you are drinking?(Required)

How often have you had 6 or more units on a single occasion in the last year?(Required)

Part one score

A score of less than 5 indicates lower risk drinking

Alcohol consumption – Part Two

Scores of 5 or more in Part 1 requires the following 7 questions to be completed

How often during the last year have you found that you were not able to stop drinking once you had started?
Never
Less than monthly
Monthly
Weekly
Daily or almost daily

How often during the last year have you failed to do what was normally expected from you because of your drinking?
Never
Less than monthly
Monthly
Weekly
Daily or almost daily

How often during the last year have you needed an alcoholic drink in the morning to get yourself going after a heavy drinking session?
Never
Less than monthly
Monthly
Weekly
Daily or almost daily

How often during the last year have you had a feeling of guilt or remorse after drinking?
Never
Less than monthly
Monthly
Weekly
Daily or almost daily

How often during the last year have you been unable to remember what happened the night before because you had been drinking?
Never
Less than monthly
Monthly
Weekly
Daily or almost daily

Have you or somebody else been injured as a result of your drinking?
No
Yes, but not in the last year
Yes, during the last year

Has a relative or friend, doctor or other health worker been concerned about your drinking or suggested that you cut down?
No
Yes, but not in the last year
Yes, during the last year

Score - part 2
0 – 7 Lower risk, 8 – 15 Increasing risk, 16 – 19 Higher risk, 20+ Possible dependence.

Total Score for alcohol questionnaire(Required)

Smoking

What is your smoking status?(Required)
Never smoked
Ex-smoker
Smoker

Do you use an e-Cigarette?(Required)
No
Ex-user
Yes

How many cigars/ cigarettes or e-cigarettes do you smoke per day?

Would you like advice/help on quitting?
Smoking is harmful to your health and we offer clinics and advice to help you give up. Would you like more information on this service? For further information please see: www.nhs.uk/smokefree
Yes
No

Height and weight

Your height:(Required)

Your weight:(Required)

Waist circumference

Would you like weight management advice?
Yes
No

For patients aged 65 and over or those with a chronic disease (e.g. asthma or diabetes)

Have you had a flu vaccination? If yes, please give the date below.

Have you had a pneumococcal vaccination? If yes, please give the date.

Women only

Have you ever had a cervical smear?
Yes
No
Don't know

Date of cervical smear
Day
Month
Year

Date pessary fitted
Day
Month
Year

Do you use a form of hormonal contraception? (Please specify type of pill, implant etc)
If needed, please book an appointment
Pill
Implant
Other

Are you currently pregnant or think you may be?
Yes
No

Expected due date

Have you had a hysterectomy?
Yes
No

When was the date of your hysterectomy?

Electronic prescribing

If you ever need any prescriptions which pharmacy would you like us to send them to?(Required)
Please note - we are now part of phase 4 of the Electronic Prescription Service (EPS) which will mean that almost all our prescriptions will be processed electronically (from April 2020)

Patient participation group

We are committed to improving the services we provide. The Patient Participation Group is a mechanism for us to gain valuable feedback from our patients about their experiences, views and ideas for improving our services.

Would you like to be involved in our Patient Participation Group?
Yes
No

Living will

Do you hold a living will?
(A Living Will is documentation regarding your personal wishes in respect of medical intervention at the time of serious illness)
Yes
No

NHS Organ and blood donation

Organ donation in England has changed to an opt out system. You still have a choice whether or not you want to become an organ donor. We will always ask your family to support your decision. So whatever you choose, it's really important that you let them know. More about the donation laws in England

Please provide details

NHS Blood Donor Registration
I am already a donor
I wish to be a donor
I do not wish to be a donor

To register:
Online: Go to the NHS Blood and Transplant website
Telephone: 0300 123 23 23 to speak to an advisor who will send out a donor card.

NHS patient information sharing - Summary Care Record

Linthorpe Surgery participates in the national Summary Care Record. This means that clinical information held by us about your medications and allergies will be available to other NHS staff involved in your care outside of the surgery. If you consent to a summary care record with additional information, it will also include your significant medical history (past and present), repeat medication, anticipatory care information (such as information about the management of long term conditions), immunisations and allergies. This can be particularly helpful if you have a lengthy or complex medical history.

Please tick the box below to let us know whether you want a Summary Care Record with Additional Information. You can change your mind at any time, just let us know.

If you would like to know more about these things, please see the following link: NHS Health Records

NHS Summary Care Record(Required)
You have the choice of what information you would like to share and with whom. Authorised healthcare staff can only view your SCR with your permission. The information shared will solely be used for the benefit of your care.
I wish information about my medical to be uploaded to the Summary Care Record with Additional Info
I wish information about my medical to be uploaded to the Summary Care Record
I DO NOT wish information to be uploaded to the Summary Care Record with Additional Info

Connecting Care record

This is a local system (Bristol) that will enable hospital and out of hours clinicians to be able to view key information from your record.(Required)
I wish key information about my medical history, medication and allergies to be uploaded to a Connecting Care record
I DO NOT wish information about my medication and allergies to be uploaded to a Connecting Care record

Date & signature

(you will be asked to sign this form when you visit the practice and provide ID and proof of address)

2 Forms of ID required within two weeks(Required)
If 2 forms of ID (Recent utility bill dated within 6 months and photo ID) are not handed in within 2 weeks this application will be destroyed.
Yes I understand my application will be destroyed if I don't provide ID within 2 weeks

Please enter your full name(Required)

Today's date
Day
Month
Year

Not for urgent medical help(Required)
Yes, I understand this form is NOT for urgent medical help

Phone
This field is for validation purposes and should be left unchanged.

Call us: 01642 856066

Register patients over the age of 5

Patient's details

Non-UK European Health Insurance Card (EHIC), Provisional Replacement Certificate (PRC) details and S1 forms

If yes, please enter details from your EHIC or PRC below:

Supplementary questions

PATIENT DECLARATION for all patients who are not ordinarily resident in the UK

S1 Form

Your next of kin

Other details

Were you ever registered with an Armed Forces GP?

About you

Communication needs

Carers

Medical information

Family history

Current medication

Alcohol consumption - How many units of alcohol do you consume in a week?

Alcohol consumption – Part Two

Smoking

Height and weight

For patients aged 65 and over or those with a chronic disease (e.g. asthma or diabetes)

Women only

Electronic prescribing

Patient participation group

Living will

NHS Organ and blood donation

NHS patient information sharing - Summary Care Record

Connecting Care record

Date & signature

Helpful links

Hearing loop enabled