New Patient Registration

If you would like to register with the practice please use this form.

To register a new patient you will need to live within our practice boundary.

Child Regsitration

If you would like to register a child, please use our U16 Registration Form. 

New Patient Registration - Heathcot

New Patient Registration - Heathcot

Section

Do you live in a residential/nursing home?
Please use date format DD/MM/YYYY.
Do you live in another EEA country, or have moved to the UK to study, retire, or live in the UK but work in another EEA member state?
Would you like to help us to improve our services by joining our virtual patient participation group?
If you are happy for us to occasionally contact you by email about what you think of our services – please select the 'yes'

Making Information Accessible

If you would like us to record your communication needs on your medical record, please indicate below:

Service Families and Military Veterans

As a practice, we fully support the Armed Forces Covenant. We can only do this if we know our patients connections to the Armed Forces.
Please tick the boxes that apply to you:

Ethnicity

Having information about patients’ ethnic groups would be helpful for the NHS so that it can plan and provide culturally appropriate and better services to meet patients’ needs.

If you do not wish to provide this information you do not have to do so.

Please indicate your ethnic origin:

Carer Status

Do you have a carer?
Are you a carer?

Next of Kin

Contacting You

We will use your contact details to send reminders about appointments, reviews and other services which may be of benefit in your medical care.
Do you consent to the Surgery sending letters to your home address?
Do you consent to the Surgery sending text messages to your mobile?
Do you consent to the Surgery sending messages to you by email?
Do you consent to the Surgery leaving messages on your phone?
(We will not leave detailed messages on your phone, but may ask you to contact us or leave a simple message if we do not need to speak to you).

Section

Sharing your medical records with others

Medical confidentiality is the cornerstone of trust between doctor & patient and we keep your medical records secure & confidential. For your direct care either from the practice or within the NHS hospital service we imply your consent to pass on relevant clinical information to other professional staff involved in your direct care.

Only when there is a legal basis for the transfer of data we may pass limited & relevant information to other NHS organisations to improve the efficient management of the NHS or to aid medical research.

Please answer the questions below so that we know how you wish us to share your data. Please see our website www.heathcotmedicalpractice.nhs.uk for details of how we may share your anonymised data.

You may change your mind at any time.

Summary care records (www.nhscarerecords.nhs.uk)

Heathcot Medical Practice is a part of the national Summary Care Record program. This enables each patient to have a summary of their key medical information held securely on the NHS central database, known as the NHS spine.  The summary record can be used in an emergency if you needed treatment when access to the medical record held by your GP was not available for example: if you call the doctor out of hours.  You will always be asked to give permission for this record to be viewed and you have the right to decline.

Please see the website above or our practice website www.heathcotmedicalpractice.nhs.uk for more information or ask at reception for a leaflet.

Please indicate below whether you would like to have your own Summary Care Record by indicating your decision below: *

Sharing your records with other community health and social care teams

We often work with other clinicians such as district nurses, community midwives, community matrons, health visitors, social services, palliative care. These teams are not employed by our Practice but they may need access to your records to support you appropriately. They abide by all of our rules regarding patient confidentiality.

Are you happy for us to share your records with the community teams that we work with to provide your health support? *

Electronic Prescribing Service (EPS)

The EPS allows prescribers – such as GPs and practice nurses to send prescriptions electronically to a dispenser (such as a pharmacy) of the patient’s choice. This makes the prescribing and dispensing process more efficient and convenient for patients and staff. The NHS aim that by 2020 they will hopefully be paper free or a paper-lite service. To help achieve this The As a practice, we would encourage all patients to opt for electronic prescribing.

Donation Wishes

Do you donate blood?

Resuscitation wishes and Power of Attorney

Do you have a DNACPR (do not attempt CPR) form in place?
Does anybody hold Lasting Power of Attorney for Health and Welfare for you?
Please supply details of who holds this and where (and supply a copy for your medical notes).

Smoking Status:

Do you smoke?
Have you smoked in the past?
Please use date format DD/MM/YYYY.
Smoking is the UK’s single greatest cause of preventable illness.
 
Stopping smoking is not easy but it can be done, and there is now a comprehensive, NHS Smoking
Cessation Service offering support and help to smokers wanting to stop, with cessation aids available on NHS prescription.
 
If you would like help and advice on how to give up smoking, please contact www.quit4life.nhs.uk or ask at reception.

Section

This is one unit of alcohol:

Amount of different types of drink representing one unit of alcohol

And each one of these, is more than one unit:

Amount of different types of drink representing more than one unit of alcoholAmount of different types of drink representing more than one unit of alcohol
How often do you have a drink that contains alcohol? *
How many alcohol drinks do you have on a typical day when you are drinking? *
How often do you have a 6 or more standard drinks on one occasion? *
How often do you have a 6 or more standard drinks on one occasion?
How often during the last year have you found that you were not able to stop drinking once you had started?
How often in the last year have you failed to do what was normally expected from you because of your drinking?
How often do you have a 6 or more standard drinks on one occasion?
How often do you have a 6 or more standard drinks on one occasion?
How often during the last year have you needed an alcoholic drink in the morning to get yourself going after a heavy drinking session?
How often during the last year have you had a feeling of guilt or remorse after drinking?
How often during the last year have you been unable to remember what happened the night before because you had been drinking?
Have you or somebody else been injured as a result of your drinking?
Has a relative or friend, doctor or other health worker been concerned about your drinking or suggested that you cut down?
If you would like help and advice on how to reduce your alcohol intake, please contact
www.drinkaware.co.uk or ask at reception.

General Practice Physical Activity Questionnaire

Please tell us the type and amount of physical activity involved in your work:
During the last week, how many hours did you spend on each of the following activities?
Physical exercise such as swimming, jogging, aerobics, footfall, tennis, gym workout etc.
Cycling, including cycling to work and during leisure time
Walking, including walking to work, shopping, for pleasure etc.
Housework/Childcare
Gardening/DIY
How would you describe your usual walking pace?
Please give measurement in Meters, i.e 1.63
Please give measurement in KG, i.e 60
If you would like advice on managing a healthy weight, please contact www.nhs.uk/live-well or reception who will be able to direct you to the most appropriate service.

Disability/Accessibility Information Standards

As a practice we want to make sure that we give you information that is clear to you. For that reason we would like to know if you have any communication needs.

Do you have any special communication needs?
Do you have significant mobility issues?
Are you housebound?
Are you blind/partially sighted?
Do you have significant problems with your speach?

Family History and Past Medical History

Have any close relatives (parent, sibling or child only) ever suffered from any of the following?
Heart Disease:
Stroke:
Diabetes:
Asthma:
High Blood Pressure:
Glaucoma:
Tuberculosis:
Thyroid Disorder:
Cancer:
Have you yourself ever suffered from any important medical illness, operation or admission to hospital? If so please enter details below:

Female Patients Only:

Have you had any children?
Are you currently pregnant?
If yes, please ensure you are under the care of a midwife. If you’re not currently under the care of a midwife please speak to reception regarding this.
Have you had a cervical smear test?
Please use date format DD/MM/YYYY.

Vaccinations

2 months DTPP and HIB:
2 Moths Pneumococcal:
2 Moths Rotavirus:
2 months Men B:
2 months Hep B (from spring 2018):
3 months DTPP and HIB:
3 months Men C:
3 months Rotavirus:
12-13 months Men B:
3 months Hep B (from spring 2018) :
4 months DTPP and HIB:
4 months Pneumococcal:
4 months Men B:
4 months Hep B (from spring 2018):
12-13 months Hib/Men C
1st MMR:
12-13 Months Pneumococcal:
12-13 months Men B:
Pre School Booster DTPP:
2nd MMR:
14 Years TD/Polio:
1st HPV:
2nd HPV:
Men C:
14 Years Men ACWY:
Over 65 Pneumococcal:
Shingles:
Tetanus:
Hepatitis A:
Hepatitis B:
Typhoid:
Japanese Encaphalitis:
Rabies:
Yellow Fever:
Seasonal Influenza: