Adult New Patient Registration Please complete the form below for each person that is registering at the practice. * = Mandatory field Patient's Details Title: * Mr Mrs Miss Ms Other Please specify: Surname: * Previous Surnames: First Name(s): * Date of Birth: * Please use this date format: DD/MM/YYYY. Gender: * Male Female NHS Number: Home Address: * Postcode: * Town and Country of birth: * Home Phone Number: * Mobile Phone Number: * Work Phone Number: Email Address: * Can we contact you by text? * Yes No Can we contact you by email? * Yes No Nationality Please specify the ethnic group you consider you belong to: * White British White Irish Other White Black Caribbean Black African Other Black Black Caribbean and White Black African and White Other Mixed Indian Pakistani Bangladeshi Other Asian I do not wish to state Other ethnic group Please state: * Do you speak English? Yes No Do you read English? Yes No First Language: Emergency Contact Full Name: * Relationship to you: * Phone Number: * Are they your Next of Kin? Yes No Do you give us permission to discuss your medical records with them? Yes No Allergies Do you have any allergies? * Yes No Please specify what you are allergic to, what happens and when you had your first reaction: * Please help us trace your previous medical records by providing the following information Previous address in UK: * Please include postcode. If not applicable, please state N/A. Name and address of previous GP: * Please include postcode. If not applicable, please state N/A. If you are from abroad Are you from abroad? * Yes No Your first UK address where registered with a GP: * If you have not been registered with a GP in the UK before, please state N/A. Date you came to live in the UK: * Please use this date format: DD/MM/YYYY. Were you previously a resident in the UK? * Yes No If previously resident in UK, date of leaving: * If you are returning from Armed Forces Previously been a resident in the UK Address before enlisting: Service or Personnel number: Please use this date format: DD/MM/YYYY. Enlistment date: Please use this date format: DD/MM/YYYY. If you need your doctor to dispense medicines and appliances* I live more than 1 mile in a straight line from the nearest chemist I would have serious difficulty in getting them from a chemist *Not all doctors are authorised to dispense medicines Carers Do you have a carer? Yes No Are you a carer for someone? Yes No Name of carer: Phone Number: Address: Do you give us permission to discuss your medical record with your carer? Yes No Name of person receiving care: Phone Number of person receiving care: Address of person receiving care: This is to be signed by the person receiving care, to give permission to share Medical Records with the person providing care. Signature of person receiving care: Dated:
