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Patient Registration

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Patient Registration

Patient Registration

To register with the Practice you must complete your NHS number details. If you don’t know this information you can contact the Practice you were previously registered with and request your NHS number information. Unfortunately, we will be unable to complete your registration without this information.

We are pleased to welcome new patients however you have to live within a 2-mile radius of the Practice. Please check the catchment area before registering.

Patient Registration

Catchment Area

Patient Registration

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

Patient Details
Previous information
Additional info
Communication
Patient Declaration

Patient Details

Title

Surname

First Name(s)

Date of Birth

Place of Birth

Previous Surname(s)

NHS Number

Gender

Male Female Other

Next to Kin

Name

Relationship to Patient

Contact Number

Registration of Children

Please be aware that we request all children MUST be registered with a legal Parent or Guardian at the practice.

Name of Parent/Legal Guardian

Relationship to Child

Full name and address of child’s school or nursery and please state if home schooled

If you can upload a picture of the childs immunisations history. If they are immunised in the UK this can be found in their red book. If they are immunized overseas then attach a picture of their schedule showing the dates of the injections.

Choose a file

Max. size: 2.0 MB

Do you have a Social Worker?

Yes No

Name of Social Worker (if applicable)

Do you have any children under 16 who do not live with you?

Yes No

If Yes, Please give details

Postcode

Address

Email

Contact Number

Alternative Number

Ethnicity

Religion

Main or 1st language spoken/understood

Proof of address – Please provide a copy of a document, not older than 3 months, that provides a proof of address.

Choose a file

Max. size: 2.0 MB

Previous details in UK

Your previous address & postcode in UK

Name of previous GP

Address of previous GP practice

If you are from abroad

Your first UK address where registered with a GP

If previously a resident in UK, date of leaving

Date you first came to live in UK

Please provide your vaccination history

Were you ever registered with an Armed Forces GP

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 & postcode before enlisting

Service or Personnel number:

Enlistment date

Discharge date (if applicable)

Footnote: 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.

Donor Registration

NHS Organ Donor registration

Do you wish to Opt-Out from NHS Organ Donation?

Yes No

I want to register my details on the NHS Organ Donor Register as someone whose organs/tissue may be used for transplantation after my death. Please tick the boxes that apply.

Any of my organs and tissue or

Kidneys

Heart

Liver

Corneas

Lungs

Pancreas

Please tell your family you want to be an organ donor. If you do not want to be an organ donor, please visit www.organdonation.nhs.uk or call 0300 123 23 23 to register your decision.

NHS Blood Donor registration

I would like to join the NHS Blood Donor Register as someone who may be contacted and would be prepared to donate blood.

Tick here if you have given blood in the last three years

Carer Information (not needed for children)

Do you have a Carer?

Yes No

If yes, are they registered at this practice?

Yes No

Carer name:

Telephone number:

Do you consent for your carer to be informed about your medical care?

Yes No

Are you a Carer? (Only if you are a registered Carer)

Yes No

If yes, do you look after someone who is a patient at this practice

Yes No

If yes, what is their name?

Are they a

Relative Friend Neighbour

Please upload a photo ID

Choose a file

Max. size: 2.0 MB

Height and Weight

Enter your height

Enter your weight

Please tell us about your smoking habits, alcohol consumption, and exercises (not needed for children)

Do you smoke?

Yes No

If yes, how many do you smoke a day?

Would you like advice on quitting?

Yes No

Are you an ex-smoker?

Yes No

Do you drink alcohol?

Yes No

If yes, How much alcohol do you drink in a week (Units)?

Do you exercise?

Yes No

If yes, How often do you exercise? (No. times per week and type(s) of exercise)

Medical Background

Have you had a Cervical Smear

Yes No

Please state where, when and the result

Please ask the surgery to fill in a disclaimer form.

What illnesses have you had and when? (Existing long term conditions)

Please list any tablets, medicines or other treatments you are currently taking: (including dose and frequency)

Are there any serious disease that affect your parents, brothers or sisters ( tick all that apply)

Diabetes

Heart Attack

Heart attack under age of 60

Bowel Cancer

Breast Cancer

High Blood Pressure

Asthma

Stroke

Thyroid Disorder

Any other important family illness?

Please detail below any specific needs you have so that practice can ensure they are identified and accommodated by taking the appropriate action.

Are you allergic to any medicines?

Yes No

If yes, please specify

Do you have any other allergies?

Yes No

List any other allergies you have (pollen, animal hair or certain foods)

Please select any Sensory Impairment you have.

Speech Hearing Sight None

Are you an Assistance Dog user?

Yes No

Please state any physical disabilities you have.

Please state any mental disabilities you have.

Please state any requirements you have to be able to access the practice premises.

Communication needs

We would like to get better at communicating with our patients. We want to make sure that you can read and understand the information we send you. If you find it hard to read our letters or if you need someone to support you at appointments, please let us know. We want to know if you need information in braille, large print or easy read. We want to know if you need an interpreter for your appointments.

Do you have any communication needs?

Yes No

What type of communication needs?

Registered partially blind

Registered blind

Deafness

Hearing loss

Do you need a format other than standard print?

Require written information in large font Require information in uncontracted Braille Require information in contracted Braille

Do you have any special communication requirements?

Uses hearing aid Uses hearing loop Uses speech to text reporter Uses sign language Uses lip speaker

Spoken language

English speaker

Yes No

Spoken Language:

Interpreter needed:

Yes No

If yes what language

Electronic Prescribing

We have electronic prescribing functionality, this will allow us to send your prescription electronically to your preferred choice of pharmacy, and will also save you time in collecting your prescription from the surgery.

Please give the name and address of your preferred pharmacy :

Consent

Your Care Connected
This practice is part of Your Care Connected (YCC), a potentially lifesaving local NHS record sharing service, implemented across Birmingham, Sandwell and Solihull to provide better, safer care. If you need to attend a local hospital, YCC makes it possible for the authorised health and care staff, who are caring for you, to securely access important medical information from your GP record to provide you with better, safer care. To learn more about YCC, visit the Your Care Connected website. If you are happy to take part, you do not need to do anything. If you visit one of the participating organisations, those treating you will be able to securely access vital information from your record to help improve the care you receive. If you do not want your information shared, you will need to opt out. To opt out, please complete an opt out form. Your practice will then process your request to not share your record.

Summary Care Record
If you are registered with a GP practice in England, you will already have a Summary Care Record (SCR), unless you have previously chosen not to have one. It will contain key information about the medicines you are taking, allergies you suffer from and any adverse reactions to medicines you have had in the past. Click here for more information.

Enhanced Summary Care Record
You can also choose to have additional information included in your SCR, which can enhance the care you receive. This information includes:
1. Your illnesses and health problems
2. Operations and vaccinations you have had in the past
3. How you would like to be treated – such as where you would prefer to receive care
4. What support you might need
5. Who should be contacted for more information about you

Do you wish to Opt-In for Enhanced Summary Care Record?

Yes No

If you wish to opt out the Summary Care Record, please click here to complete an opt out form.

This practice uses a text messaging service to remind patients of appointments and remind patients when they are due for a review. If you provide a mobile number when registering, you will automatically be opted in to receive text messages. If you wish to opt out, please click the checkbox.

Yes, I wish to Opt-Out mobile notifications.

Please select one or more preferred method of contact

Landline

Mobile

I declare that the information provided on this form is correct to the best of my knowledge

Yes

Do you consent to receive text messages

Yes No

Do you consent to receive correspondence via email

Yes No

I consent to being contacted via the details given above. I agree to the privacy policy

Yes

To view our privacy policy, click here

Some required Fields are empty
Please check the highlighted fields.

Catchment Area

St Heliers Medical Practice Practice Boundary Map (2 mile radius)

Boundary Map

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St. Heliers Medical Practice

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