New Patient Registration

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All questions marked with a * are mandatory

Patient's Details
Title: *
Are you happy for us to contact you by text message? : *
Do you have a nominated pharmacy for electronic prescribing?:
Nominate a pharmacy means we can send any prescriptions directly to the pharmacy without you needing to come to the surgery
include the full address and post code of your chosen pharmacy
 
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Emergency Contact
Are they your Next of Kin?:
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Previous Details
Are you registering for the first time in the UK? : *
Have you recently moved to the UK: *
Please include postcode
Are you returning from abroad?: *
If you are from abroad
Please use this date format: DD/MM/YYYY
Refugee: *
Asylum Seeker: *
Are you returning from abroad? : *
If you are returning from abroad

This assumes that you have previously been registered with the NHS in the UK

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Allergies
Do you have any allergies?: *
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Were you ever registered with an Armed Forces GP
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:
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Carers

A carer is anyone, including children and adults who looks after a family member, partner, or friend who needs help because of their illness, frailty, disability, a mental health problem or an addiction and cannot cope without their support.

  • This is different from normal parenting duties for a child
Do you have a carer?: *
UK number only
If a company of organisation, please indicate which above.
Do you give us permission to discuss your medical record with your carer?: *
Are you a carer for someone?: *
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Current Smoking Status
Your Smoking Status
Please choose from one of the following options: *
Stop Smoking

Steps to quit smoking

Stopping smoking lets you breathe more easily. People breathe more easily and cough less when they give up smoking because their lung capacity improves by up to 10% within 9 months.

  NHS Stop Smoking Services

  Take steps now to stop smoking

  10 self-help tips to stop smoking

Are you interested in further advice and support on how to quit?: *
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Your Personal Alcohol Consumption

What does 1 unit of alcohol look like?

Each of the examples depicts 1 unit of alcohol based on the Alcohol by Volume (ABV) against the Volume (ml) displayed.

Click here for NHS guidance about calculating alcohol units

  • Cider

    Cider 218ml

    Standard 4.5% ABV

  • Wine

    Wine 76ml

    Standard 13% ABV

  • Whisky

    Whisky 25ml

    Standard 40% ABV

  • Beer

    Beer 250ml

    Standard 4% ABV

  • Alcopop

    Alcopop 250ml

    Standard 4% ABV

How often did you have a drink containing alcohol in the past year?: *
 
How many drinks containing alcohol did you have on a typical day when you were drinking in the past year?: *
How often did you have six or more drinks on one occasion in the past year?: *
Your Personal Alcohol Consumption - Part 2
How often during the last year have you found that you were not able to stop drinking once you had started?: *
How often during the last year have you failed to do what was normally expected from you because of your drinking?: *
How often during the last year have you needed an alcoholic drink in the morning to get yourself going after a heavy drinking session?: *
How often during the last year have you had a feeling of guilt or remorse after drinking?: *
How often during the last year have you been unable to remember what happened the night before because you had been drinking?: *
Have you or somebody else been injured as a result of your drinking?: *
Has a relative or friend, doctor or other health worker been concerned about your drinking or suggested that you cut down?: *
 
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Audit Score Result 0 - 7 (Lower Risk)

Lower Risk 

, you have a score of 

Your answers suggest you are at a lower risk of being dependent on alcohol.

  • If you are drinking less than 14 units of alcohol per week, then your drinking is within the UK Chief Medical Officers' low risk drinking guidelines.

Caution advised

If you are drinking regularly at or above the low risk guidelines of 14 units a week, or, you are drinking six or more units if you are female or eight or more units  if you are male in one single session (binge drinking), please consider the increased serious risks to your health being caused by your current drinking pattern.

Audit Score Result 8 - 15 (Increasing Risk)

Increasing Risk

, you have a score of 

Your answers suggest you are at an increasing risk of being dependent on alcohol.

Caution

  • Your drinking is dangerous to your health, increasing your risk of serious health problems including seven types of cancer, liver and heart disease, and high blood pressure.
  • Unless you cut down you are at risk of damaging your health.
Audit Score Result 16 - 19 (Higher Risk)

Higher Risk

, you have a score of 

Your answers suggest you are at Higher Risk of being dependent on alcohol.

Your drinking is dangerous to your health.

  • You are drinking far more than the UK Chief Medical Officers' low risk drinking guidelines of 14 units a week.
  • Regularly drinking this much causes a range of serious health harms including seven types of cancer, liver disease and high blood pressure.
Audit Score Result 20+ (Possible Dependence)

Possible Depandance

, you have a score of 

Your answers suggest you are at High Risk of being dependent on alcohol.

  • Your drinking is dangerous to your health.
  • You are drinking far more than the UK Chief Medical Officers' low risk drinking guidelines of 14 units a week.
  • Regularly drinking this much causes a range of serious health harms including seven types of cancer, liver disease and high blood pressure.

Alcohol Support

If you have become dependant on alcohol, you will have found it difficult to fully control your drinking in some way. So you'll probably need some help either to cut down and control your drinking or stop completely, and also some plans to maintain the improvement after that.

  Find Alcohol Support Services in your area

  Tips on cutting down

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Weight and Height

Your Weight

What unit of measurement are you using?: *
Conversion from Stones & Pounds to Kilograms

Your Height

What unit of measurement are you using?: *
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Summary Care Record

Summary Care Record (SCR)

The Summary Care Record (SCR) system is designed to help both your GP and any emergency staff you contact when the surgery is closed to treat your health needs more efficiently.

  • Your information will be shared between your GP practice, our local hospital and Out Of Hours service.
  • This will enable your GP surgery to access results and any visits you have at the hospital quickly and efficiently, but it also means that if you have an emergency and contact the Out Of Hours service or visit A&E they will have access to your current medications as well as allergies and are better able to treat you.
SCR Options:

If you do not complete this section, a Summary Care Record will be created for you based on implied consent

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Identification
Only following file extensions are allowed: jpg, jpeg, png, webp, pdf, doc, docx, pptx
Only following file extensions are allowed: jpg, jpeg, png, webp, pdf, doc, docx, pptx
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Patient Signature

Privacy Consent

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