Download New Patient Registration Information

New Patient Registration Information
How to Register
To register with the Practice patients should:
 collect the registration forms from the surgery
 complete all the forms and return them to the surgery along with appropriate ID
 once we have received your completed forms we can process this within 2 working days
 once registered, patients can follow the standard procedure to book appointments and order
prescriptions
 Please return your forms to the surgery after 11am in a morning. This will enable the reception staff
to have more time to deal with your registration effectively.
New Patient Acceptance / Refusal
New patients should complete a New Patient Registration Form and GMS1 form.
Patients are also required to produce evidence of their identity and address, e.g. photo driving licence,
passport and a utility bill.
For children aged 6 and under, evidence of immunisations should be produced. This is either the ‘Red
Book’ or other documentary evidence of immunisation status.
Please note the following points:
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If you are not yet registered with our practice and you (or your representative) feel that the
condition is of an "urgent" nature then you can ring NHS 111 (dial 111) and obtain further advice
about the most appropriate and safe place to be treated.
Until we receive your medical records from your previous doctor, it is your responsibility to provide
us with accurate details of any medications you are taking. This can be done by producing the right
hand side of your prescription or you contacting and obtaining a list of your medications from your
previous GP.
The registration process must be completed before you can see a doctor or nurse at the surgery.
Registering as a new patient is a routine process, and not an urgent or emergency procedure.
New Patient Registration Information V2.docx
MONTAGUE MEDICAL PRACTICE
NEW PATIENT QUESTIONNAIRE
Mr / Mrs / Miss / Ms / Other
Full Name:
Date of Birth:
Address and postcode:
Telephone
Mobile
number:
number:
Do you consent to receive text message reminders about appointments?
Yes / No
Town & Country of birth:
Marital status:
Male / Female
Occupation:
If applicable, date you first came to live in Britain:
Nationality
(please tick)
British
Latvian
Polish
Portuguese/Brazilian
Other
Your main or 1st
language
understood
(select one)
English
Latvian
Polish
Portuguese/Brazilian
Spanish
Russian
Ukrainian
Hindi
Urdu
Punjabi
Other (please specify)
Your ethnic
origin:
White (UK)
White (Irish)
White (Other)
Chinese
Bangladeshi
Pakistani
Ethnic
Category
not stated
African
Other Asian
Background
Other Mixed
Background
Smoking history: Do you smoke?
Other Black
Background
Weight:
Yes
If yes: how many per day………………………………..
No
Never
Date stopped:………………………………………….
Yes
No
How many units per week:………………………………………………………..
New Patient Registration Information V2.docx
Asian
Other (Please state)
Height:
Alcohol: Do you drink alcohol?
Caribbean
Indian
Family history: have your parents, brothers or sisters ever suffered with the following:
Yes
No
Age of
onset
If yes, please give details of illness & relationship to
you
Diabetes
Angina
Heart Attack
Stroke
High Blood Pressure
Cancer
Asthma
Epilepsy
Your past medical history: Do you have, or have you had any serious illness or any operations?
Please give details
Name of
medication
0. Example tablet
Please list any tablets,
medicines or other
treatments you are
currently taking:
(incl. dose + frequency)
If you have the right hand side of
your prescription from your
previous doctor please attach to
this form
Strength of
medication
600mg
Dose and
frequency
1 tab once daily
1.
2.
3.
4.
5.
Please continue on separate sheet if needed
Allergies: Do you have any allergies to medication, e.g Penicillin, Elastoplast?
Please give details
New Patient Registration Information V2.docx
Reason for use (if
known)
Joint pain
Women only:
When was your last smear done?
Was this at your GP surgery?
What was the result?
Patient Participation Group
The Practice is committed to improving the services we provide to our patients.
To do this, it is vital that we hear from people about their experiences, views, and ideas for improving
services.
By expressing your interest, you will be helping us to plan ways of involving patients that suit you.
It will also mean we can keep you informed of opportunities to give your views and up to date with
developments within the Practice.
If you are interested in getting involved, please tick the box below and we will arrange for details of the
Patient Participation Group to be sent to you.
Yes, I am interested in becoming involved in the
Yes
Practice Patient Participation Group (Please tick the
“Yes” Box)
Patient
Signature
New Patient Registration Information V2.docx
Date