The Verwood Surgery New Patient Registration Form

Welcome to The Verwood Surgery. To accurately register you with the surgery, please complete this questionnaire. You must also provide photographic proof of ID (e.g. passport or a UK photo driving license) and proof of residency (e.g. current utility bill, recent bank statement or letter from host family/college) at your first visit.

Please note your registration cannot be accepted until the forms are completed in full, with all requested details and proof of ID and residency. Thank You

Last Updated: 07/03/2024

Patient's Details

With regard to contact details, it is important that we have up to date information in case we need to contact you. We will use these details to call, text or email you about health care services. All phone numbers must be registered in the UK.

Title *

Surname *

Previous Surname (if applicable)

First name(s) *

Date of Birth (DD/MM/YYYY( *

Gender

Male

Female

Preferred prounouns

NHS number - while not mandatory, this helps us find your medical records or transfer them from your current GP. more quickly)

Street Address *

Postcode *

Town and country of birth *

Telephone number (preferably a mobile phone number if this is the quickest way to contact you) *

Email address *

Are you happy for us to contact you by email? *

Yes No

Are you happy for us to contact you by Text Message?

Yes No

Do you have a preferred pharmacy for Electronic Prescribing *

Yes No

If yes, which pharmacy?

Occupation *

Live with

Supplementary Contact Information

Next of Kin

Relationship (to next of kin)

Contact Number (next of kin)

Is your Next of Kin your Emergency Contact? If no, please complete the next Emergency Contact questions below. *

Yes No

Emergency Contact Full Name

Emergency Contact relationship to you

Emergency Contact Telephone Number

Do you give us permission to discuss your medical records with your Emergency Contact *

Yes No

Do you have a designated carer? If Yes, please provide details *

Yes No

Name and details of Carer

Are you a carer for someone else? (If yes, please provide details) *

Yes No

I care for (name and their relationship to you)

Please help us trace your previous medical records by providing the following

You only need to complete this section if you have NOT provided your NHS number to enable us to trace your previous medical records.

Your previous address in UK

Are you registering for the first time in the UK? If yes, please advise us of your date of arrival in the UK below.

Yes No

Date of arrival in the UK

Are you returning from abroad?

Yes No

Name of previous GP while at previous address

Address of that Doctor/ Surgery

Supplementary questions regarding UK residency

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. If you are visiting from another EEA country and do not hold a current EHIC (or Provisional Replacement Certificate (PRC)/S1, you may be billed for the cost of any treatment received outside the GP practice, including at hospital).

I am not ordinarily a resident in the UK *

Yes No

Do you live another EEA (European Economic Area) country or have you moved to the UK to study or retire, or live in the UK but work in an EEA member state? *

Yes No

I have an S1 form (e.g. you are retiring to the UK or you have been posted here by your employer for work oryou live int he UK but work in an EEA Member state)

Yes No

If you are returning from the armed forces

Have you ever served in the Armed Forces *

Yes No

Would you like to be added to the Practice Military Veterans register?

Yes No

Ethnicity Details

This is not compulsory, but may help with your healthcare, as some health problems are more common in specific communities, and knowing your origins may help with the early identification of some of these conditions.

Health and Lifestyle Questions

Please provide as much information as possible as this will help your GP give you the best care.

For female patients

Have you had a hysterectomy?

Yes No

Do you have your ovaries

Yes No

NHS Blood and Organ Donor Registration

Since October 2021, patients’ blood and organ donation preferences are no longer being processed through GP practices. For information about registering as a blood or organ donor, please visit the NHSBT donation information website page by following this link>>

Complete Registration

If you are registering a child under 5

I wish the child above to be registered with the named doctor for Child Health Surveillance

Signature *

Signature of patient

Signature on behalf of patient

Signed

Date

CONSENT AND DATA SHARING

If any of the details on this form change in the future, please inform us. In accordance with the Data Protection Act, the Practice needs consent from any patient for us to leave a message, send a text or information regarding their medical treatment. By providing the information on this form you are consenting to be contacted about your medical needs. The Barcellos Family Practice uses System One clinical software. This enables us to share your record with any other NHS organisations who are involved in your healthcare. To opt out of sharing, please speak to the receptionist or advise us in writing.

Data Sharing Consent Choices (Summary Care Record & Dorset Shared Record)

To maintain continuity of clinical care, we upload certain medical information so that it is available to other healthcare organisations (e.g. Emergency Departments). Please download and view this information leaflet, which details which part of your record is extracted and how it is used to help other NHS organisations.

Consent to share your patient record with any other NHS organisations who are involved in your healthcare *

I consent to sharing data and medical information with other NHS organisations involved in my healthcare

We ask for your consent to begin communicating with you by text or email. We ask you to confirm: *

I consent to the practice contacting me by text message or email for the purposes of health promotion, practice news and for appointment reminders

I acknowledge that appointment reminders by text are an additional service and that they may not be sent on all occasions but that the responsibility for attending appointments or cancelling them still rests with me.

Text messages are generated using a secure facility, but I understand that they are transmitted over a public network onto a personal telephone and as such may not be secure.

I understand I can cancel the text message facility at any time.

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The Verwood Surgery New Patient Registration Form

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