New Patient Registration

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All questions marked with a * are mandatory

Patient's Details
Title: *

Sex, Gender & Identity

The practice follows the PCSE electronic registration process and their predetermined questions. This process limits the practice on the types of gender identity options we can offer. For the purpose of this registration, it is important that patients inform us of their birth gender so that we can arrange the smooth transfer of medical records from your previous practice.

Downend Health Group understands that there are occasions when a patient may wish to change their gender. The practice treats such changes with care, sensitivity and in the most appropriate way. Patients do not need to have undergone any form of medical re-assignment for this change to be officially recognised and a Gender Recognition Certificate (GRC) is no longer deemed necessary. Please let us know if you wish to change your name, title and/or gender markers on your healthcare records so that we can discuss the options with you.

The practice has appointed a designated Gender Identity Lead with the expectation of providing a high-quality service and to promote respect, dignity and equality for trans patients. The Lead participates in regular training programmes on gender dysphoria and promotes awareness amongst the DHG team.

Gender at birth: *
Do you identify differently?:
Can we contact you via email: *
Please note that we may send you information of a confidential nature using a secure network. it is the patient’s responsibility to ensure their email is protected from malware.
Can we contact you via Text: *
Can we contact you via mobile telephone: *
Can we contact you via home telephone: *
Can we contact you via letter: *
Preferred Pharmacy for dispensing

Please provide the name, address and postcode of your preferred pharmacy.

Alternatively, you can tell your local chemist that you would like to choose them as your nominated pharmacy, and they will do the rest for you.

Please note, we can only accept pharmacy nominations located in England. We are unable to set up nominated pharmacies in Wales or Scotland.

Would you like to nominate a pharmacy?: *

Please tell your local chemist that you would like to choose them as your nominated pharmacy, and they will do the rest for you.

Legal Guardian

The following questions are about the details of the Legal Guardian (i.e. Main Parent, Guardian or Carer) for  

Is the legal guardian registered at this practice?: *

Children cannot be registered unless their legal guardian is a patient at this practice, or unless they are planning to register at the same time.

You cannot continue with this application: *
Legal Guardian's Details
Legal Guardian's Title: *
Is the Birth Father named on the child's birth certificate?: *

You will be required to include copy of the Birth Certificate as proof later in this form.

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NHS

Your NHS Number

Help us to help you

You do not need to know your NHS number to use NHS services. However, providing this reduces the time it takes to process your registration. It helps us get you registered quicker.

  How to find your NHS Number

Help us to help you.

 

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Ethnicity & Religion
I am: *
Do you speak English?:
Do you read English?:
Will you require an interpreter when you see the doctor/nurse?:
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Next of Kin
Title: *
Please include their Postcode
Emergency Contact
Is your Emergency Contact the same as your Next of Kin?: *
Title: *
Please include Postcode
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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. If there is no previous address, please state "NONE"
If there is no previous GP please state "NONE"
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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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:
Please specify the field(s) in which you were enlisted:
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Supplementary Questions - If you are not a resident in the UK, but visiting or moving to the UK
New Patient Registration

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 at reception. Alternatively for more information go to the NHS Website

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 statements:: *
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European Economic Area (EEA) Country
Do you live in another EEA country, or have moved to the UK to study or retire, or live in the UK but work in another EEA member state?:
Do you have a non-UK European Health Insurance Card (EHIC) or a Provisional Replacement Certificate (PRC) ?:

Please Note

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 of the GP practice, including at a hospital.

Please enter the details from your EHIC or PRC below.

S1 Form

Please upload a copy of your S1 form

  • You can upload a document, photo or scan
Only following file extensions are allowed: jpg, jpeg, png, webp, pdf, doc, docx, pptx

How will your 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.
  • This form collects personal and medical information about you and we use this information to allow the practice team to contact you.
  • 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.
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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.

You're a young carer if you're under 18 years old and help to look after a relative with a disability, illness, mental health condition, or drug or alcohol problem.

  • 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?: *
Are you a young carer?: *
You're a young carer if you're under 18 years old and help to look after a relative with a disability, illness, mental health condition, or drug or alcohol problem.

This section does not require completing due to the age of the patient.

Please continue to the Next Page

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Allergies
Do you have any allergies?: *
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Additional Information

Your Height

What unit of measurement are you using?: *
Conversion from Feet & Inches to Centimetres

Your Weight

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

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

Adult Females
Was it done at:
Have you had a hysterectomy?:
Do you still have your ovaries?:
Accessibility Questions
Do you have any accessibility needs to help you read our letters and/or mobile communications?: *
Do you need information in braille, large print or easy read?: *
Do you need a British Sign Language interpreter or advocate for any appointments?: *
Do you need support to lipread or use a hearing aid or communication tool?: *
Do you have any special communication requirements?: *
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Have you had any of the following Immunisations
1st Dose 6 in 1 vaccine: (Whooping cough (pertussis), Tetanus, Diphtheria, HIB (Haemophilus influenzae type B), Hepatitis B & Polio) - Usually administered at 8 weeks: *
1st Dose Rotavirus Vaccine - Usually administered at 8 weeks: *
1st Dose Meningitis B Vaccine - Usually administered at 8 weeks: *
2nd Dose 6 in 1 vaccine: (Whooping cough (pertussis), Tetanus, Diphtheria, HIB (Haemophilus influenzae type B), Hepatitis B & Polio) - Usually administered at 12 weeks: *
2nd Dose Rotavirus Vaccine - Usually administered at 12 weeks: *
1st Dose Pneumococcal (PCV) Vaccine - Usually administered at 12 weeks: *
3rd Dose 6 in 1 vaccine: (Whooping cough (pertussis), Tetanus, Diphtheria, HIB (Haemophilus influenzae type B), Hepatitis B & Polio) - Usually administered at 16 weeks: *
2nd Dose Meningitis B Vaccine - Usually administered at 16 weeks: *
1st Dose Haemophilus influenzae & Meningitis C (Hib/Men C) - Usually administered at 1 years: *
1st Dose MMR Vaccine - Usually administered at 1 years: *
2nd Dose Pneumococcal (PCV) Vaccine - Usually administered at 1 years: *
3rd Dose Meningitis B Vaccine - Usually administered at 1 years: *
Annual Influenza (Flu) Vaccine - Usually administered between 2 to 10 years: *
2nd Dose MMR Vaccine - Usually administered at 3 years 4 months: *
4 in 1 Vaccine: (Diphtheria, Tetanus, Whooping Cough & Polio) - Usually administered at 3 years 4 months: *
HPV Vaccine - Usually administered at 12 to 13 years: *
3 in 1 vaccine (td/IPV): (Tetanus, Diphtheria & Polio) - Usually administered at 14 years: *
Meningococcal Conjugate (MenACWY) - Usually administered at 14 years: *
Have you had any of the following Immunisations
Pneumococcal (PPV) Vaccine - Usually offered at the age of 65: *
Annual Influenza (Flu) Vaccine - Usually offered when over the age of 65: *
Shingles (Herpes Zoster) Vaccine (Single dose) - Usually offered when over the age of 70: *
Shingles (Herpes Zoster) Vaccine (1st Dose) - Usually offered to patients with a weakened immune system: *
Shingles (Herpes Zoster) Vaccine (2nd Dose) - Usually offered to patients with a weakened immune system: *
Immunisation History
Please include dates.

This section does not require completing due to the age of the patient.

Please continue to the Next Page

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Medical History
Please include dates.
Please include dates.
Please include dates.
Please make sure you have a month’s supply from your previous practice and please arrange to make an appointment with your new doctor to review your ongoing medication.
How do you describe your sight?:
How do you describe your hearing?:

Over 75 years old?

  • The Department of Health has advised that all patients of 75 years and older have a named and accountable GP to oversee their care.
  • Please ask the name of the GP assigned to oversee your care.
  • Please note this does not prevent you from seeing the GP of your choice.
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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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NHS Logo

Patient  Identification

Help us to help you

You do not need to provide proof of address or ID to use NHS services. However, providing this reduces the time it takes to process your registration. It helps us get you registered quicker.

Acceptable forms of Photo ID

  • Photo Driving License
  • Passport

ID documents are not stored and will be securely destroyed in line with our data retention schedule.

Acceptable forms of Proof of Residence

  • Tenancy agreement
  • Mortgage statement
  • Bank statement
  • Utility bill (date within the past 3 months) 

Please upload a copy of your ID and Proof of Address

  • You can upload a document, photo or scan
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
Only following file extensions are allowed: jpg, jpeg, png, webp, pdf, doc, docx, pptx
School
Is the child attending school?: *
Please include the Postcode
Social Services
Does the child/family have any contact with a social worker?: *
Document Uploads

Please upload a copy of the following documents

  • You can upload a document, photo or scan
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
Only following file extensions are allowed: jpg, jpeg, png, webp, pdf, doc, docx, pptx
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Organ Donation

NHS Organ Donor registration

The law around organ donation in England changed to an opt-out system, to enable more people to save more lives.

This means that unless you choose to opt out, or are in an excluded group, you will be considered to have agreed to be an organ donor when you die.

The best way to make your decision known is to record it on the NHS Organ Donor Register and tell your loved ones.

  Find our more about Organ Donation

Yes I do donate

Across the rest of the UK

This section does not require completing due to the age of the patient

Please continue to the Next Page

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Blood Donor

NHS Blood Donor registration

Giving blood saves lives.The blood you give is a lifeline in an emergency and for people who need long-term treatments.

This means that unless you choose to opt out, or are in an excluded group, you will be considered to have agreed to be an organ donor when you die.

The best way to give blood is to apply using the NHS Blood Donor Register

  Find our more about Blood Donation

Yes I do donate

We need

  • Nearly 400 new donors a day to meet demand
  • Around 135,000 new donors a year to replace those who can no longer donate
  • 40,000 more black donors to meet growing demand for better-matched blood
  • 30,000 new donors with priority blood types such as O negative every year
  • More young people to start giving blood so we can make sure we have enough blood in the future

This section does not require completing due to the age of the patient.

Please continue to the Next Page

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What happens to my information?

  • Personal and medical information about patients registered at this practice are primarily kept electronically, although some is kept in paper form. Some information will be sent to hospital consultants and other health professionals to whom you are referred by your GP in order to provide continued healthcare and obtain treatment for you.
  • We sometimes use accredited suppliers for our communication with you, for example when we send recall letters for review clinics or medication reviews. All suppliers we use are checked carefully to ensure they comply with strict confidentiality protocols.
  • To ensure the security of all patient information, all staff that has access to your records is covered by confidentiality clauses in their contracts and the Data Protection Act and the Freedom of Information Act. Our guiding principle is that we hold your records in strict confidence.
Legal Guardian Signature

What happens to this information?

  • Personal and medical information about patients registered at this practice are primarily kept electronically, although some is kept in paper form. Some information will be sent to hospital consultants and other health professionals to whom you are referred by your GP in order to provide continued healthcare and obtain treatment for you.
  • We sometimes use accredited suppliers for our communication with you, for example when we send recall letters for review clinics or medication reviews. All suppliers we use are checked carefully to ensure they comply with strict confidentiality protocols.
  • To ensure the security of all patient information, all staff that has access to your records is covered by confidentiality clauses in their contracts and the Data Protection Act and the Freedom of Information Act. Our guiding principle is that we hold your records in strict confidence.

You are signing this as   the of  

You are signing this as   the legal guardian of  

  • You have listed the reason for being the legal guardian as: 
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Privacy Consent

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