New Patient Questionnaire

To submit a registration request. Please complete this form along with a new patient registration form. 

Proof of Immunisations must be provide for children under 5. Please bring this to Reception.

You may be asked for photo ID and proof of address when attending the Practice.

Last Updated: 21/05/2024

  • Your Details

    Date of Birth
    For example, 15 3 1984
    Are you a Carer for someone?
    Do you have a Carer?

  • Information About You

    Ethnic Group

  • Medical Information

    Have you ever suffered from? (tick as appropriate) (optional)
    Are you registered disabled?
    Are you allergic to any medicines?

  • Family History

    What is your family health history? Please choose serious diseases/conditions that apply.

  • Women

    Have you had a Mammogram?
    Do you take a contraceptive Pill?
    Please advise If you are using a different method of Contraception,? (optional)

  • Lifestyle

    Do you smoke?
    Would you like advice on giving up smoking?

  • Alcohol

  • Contacting You

    Do you agree that you may be contacted from time to time, via email and/or SMS, with practice news, advice about my health and/or appointment reminders.

  • KIS (Key Information Summary) Consent

    In order to improve the information available to the Out of Hours service (GMED) and Secondary Care (Hospital Staff)It is now possible to share some of the key information in your GP records electronically. In order for this to happen we need your consent. This information can only be accessed by clinicians that require it, and it includes major health issues and medication. We feel this can only help the care they are able to provide you and so would encourage you to give your permission

    Do you consent to KIS (key information Summary) Sharing?

  • Signature

    Date
    For example, 15 3 1984
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