Redbank Surgery

HOW DO I....
Register With The Practice?

TEL: 01234 567890
Fax: 01234 567890

If you wish to join our practice please ask a receptionist for a registration form for each person that wishes to join.

The form will ask you for personal details such as your name, address, date of birth and your previous doctor’s name and address. This will assist in tracing your medical records as quickly as possible.

Once you have completed and signed the form you will be placed on the list of the doctor of your choice.

You will then be sent a new medical card with your doctor’s name on for you to keep.

During the registration process the receptionist will make you an appointment with the practice nurse for a new patient check.

You can also register by internet, inserting your details below.

Security note: Electronic transmissions on the Internet are not always secure and theoretically it is possible for the details emailed from this form to be intercepted by a third party. If you have any concerns, we advise you to visit the surgery and present your details in person.

PATIENT DETAILS

Title:	Mr Mrs Miss Ms Other
First names:
Surname:
Previous Surname:
Town & Country of Birth:
Date of Birth:	01 02 03 04 05 06 07 08 09 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 01 02 03 04 05 06 07 08 09 10 11 12 1895 1896 1897 1898 1899 1900 1901 1902 1903 1904 1905 1906 1907 1908 1909 1910 1911 1912 1913 1914 1915 1916 1917 1918 1919 1920 1921 1922 1923 1924 1925 1926 1927 1928 1929 1930 1931 1932 1933 1934 1935 1936 1937 1938 1939 1940 1941 1942 1943 1944 1945 1946 1947 1948 1949 1950 1951 1952 1953 1954 1955 1956 1957 1958 1959 1960 1961 1962 1963 1964 1965 1966 1967 1968 1969 1970 1971 1972 1973 1974 1975 1976 1977 1978 1979 1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011
Are you:	Male Female
NHS No:	- -
I am NOT a student
I AM a student at:
Email Address:
Current Address:
Postcode:
Work Telephone:
Home Telephone:
Mobile:

PREVIOUS MEDICAL RECORDS

Your previous address in UK
Postcode:
Previous GP Details
Name of previous doctor :
Address of that doctor:
Postcode:
ARE YOU FROM ABROAD?	Please select Yes No
Please make your selection above. Please move to the next section.
Your first UK address where registered with a GP
Postcode
Other Details
If previously resident in UK, date of leaving
Date you first came to live in UK

Are You Returning From The Armed Forces?

Are you returning from the armed forces? Please select Yes No
Please make your selection above. Please move to the next section.
Address before enlisting
Postcode
Service Details
Service or Personnel Number
Enlistment date

If You Need Your Doctor To Dispense Medicines And Appliances*

I live more than 1 mile in a straight line from the nearest chemist	Please select Yes No
I would have serious difficulty in getting them from a chemist	Please select Yes No
*not all doctors are authorised to dispense medicines

NHS Organ Donor Registration

I would like to join the NHS Organ Donor Register as someone whose organs may be used for transplantation after my death.	Please select Yes No
Please check as appropriate:-
Kidneys Heart Liver Corneas Lungs Pancreas Any part of my body

Patient Health Questionnaire

Height:	metres: cm: feet: inches:
Weight:	kilogrammes: stones: lb:
Do you smoke?	Smoker Ex-Smoker Never-Smoked
In a week how much alcohol do you drink (in units)?
00 01 02 03 04 05 06 07 08 09 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 (1 unit = ½ pint beer or lager, 1 single measure of spirit or 1 medium glass of wine) How often do you have a drink containing alcohol? Never Monthly or less 2-4 times a month 3-4 times a week 4+ times a week How many drinks do you have on a typical day when you were drinking in the past year? None, I don't drink 1 or 2 3 or 4 5 or 6 7 to 9 10 or more How often do you have six or more drinks on one occasion in the past year? Never Less than monthy Monthly Weekly Daily or almost daily
Do you suffer with any of the following medical conditions?
Asthma Epilepsy Hypertension Diabetes Heart Disease Stroke
Have your parents, brothers or sisters suffered from any of the following medical conditions?
Asthma Father Mother Brother Sister Grandparents Diabetes Father Mother Brother Sister Grandparents Epilepsy Father Mother Brother Sister Grandparents Heart Disease Father Mother Brother Sister Grandparents Hypertension Father Mother Brother Sister Grandparents Stroke Father Mother Brother Sister Grandparents
Blood Pressure
As part of our new patient health screening program we require a blood pressure recording for all new patients. we have an automatic blood pressure machine in our waiting room which you can come in and use without appointment and it is extremely simple to use.
Cervical Cytology (female patients only)
01 02 03 04 05 06 07 08 09 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 01 02 03 04 05 06 07 08 09 10 11 12 1960 1961 1962 1963 1964 1965 1966 1967 1968 1969 1970 1971 1972 1973 1974 1975 1976 1977 1978 1979 1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 what was the date of your last smear test?
Please select Negative Positive Not Known what was the result of your last smear test?
Carers
Please select Yes No Are you cared for by someone either on a Full or Part time basis?
Please select Yes No Do you care for someone either on a Full or Part time basis?

Ethnic Origin Monitoring Form

In compliance with the Race Relations (Amendment) Act 2000 and its Race Equality Scheme any new patient registrations are requested to complete this form. Please tick the appropriate box to indicate your ethnic origin:
British or mixed British English Irish Scottish Welsh Other (specify if you wish) Black African Caribbean Other black background (specify if you wish) Mixed ethnic background Asian and white Black African and white Black Caribbean and white Other mixed ethnic background (specify if you wish)	Asian Bangladeshi Indian Pakistani Any other (specify if you wish) Chinese Chinese Any other (specify if you wish) White Any white background (specify if you wish) Any other ethnic background Any ethnic background (specify if you wish) Other Ethnic Background Specify Here
Main language spoken:

Sending this form does not guarantee or even imply that you will be accepted onto the practice register.

CONFIDENTIALITY - TERMS AND CONDITIONS:
The internet is not secure, and the transmission of this data is entirely at the patient's own risk. The practice accepts no responsibility for breaches in confidentiality resulting from patients' transmissions.

I can't see a padlock - is this secure?

Click 'Submit' to send your details to the surgery.