New Patient Registration Form

For us to be able to correctly process your registration it is important that the whole form is completed accurately. Please note;

You should only send this form if you are sure that you are eligible to join this practice.
Sending this form will not automatically register you with the surgery.
Sending this form does not guarantee or even imply that you will be accepted onto the practice register

Please note that by using this form you will be sending information about yourself across the Internet. Whilst every effort is made to keep this information secure, you should be aware that we cannot offer any guarantees of absolute privacy. If this matter concerns you then you should use another method of registration. Personal information retained on this system is stored in a secure data centre located in the UK and is treated as confidential.

Please select the practice location most relevant to this Online Form submission:

Title

Forename

Surname

Previous Surnames

Date of Birth

Birth Town

Birth Country

Faith

Home Telephone Number

Mobile Telephone Number

Email address

NHS Number

Sex

Address

Post Code

Weight (kgs)

Height (cms)

Are you a student? If so please specify where:

Preferred method of communication.

Do you give consent, if necessary for us to leave an answerphone message

Please provide details or any learning difficulties or disabilities you would like us to be aware of

Please select the option that best describes your ethnic origin

If you answered 'other' for the ethnic group please specify here

First spoken language

If you answered 'other' for the first spoken language please specify here

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

Previous address in UK

Name of previous doctor while at that address

Address of previous doctor

If you are from abroad

Your first UK address where registered with a GP

If previously resident of UK, date of leaving

Date you first came to live in UK?

If you are returning from the Armed Forces

Address Before Enlisting

Service or Personnel Number

Enlistment Date

If you are registering a child under 5

I wish the child above to be registered with the doctor named below for Child Health Surveillance.

If you need your doctor to dispense medicines & appliances*

*Not all doctors are authorised to dispense medicines

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

Signatures

Are you the patient or completing the form on behalf of the patient to be registered?

NHS Organ Donation Registration

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.

For more information, please ask for the leaflet on joining the NHS Organ Donor Register

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 give blood.

I have given blood in the last 3 years

For more information, please ask for the leaflet on joining the NHS Blood Donor Register

Preferred address for donation: (if different from above, e.g. place of work)

EPS Required

The Electronic Prescription Service (EPS) allows prescriptions to be sent direct to pharmacies through IT systems used in GP surgeries. Eventually EPS will remove the need for most paper prescriptions. 99.3% of pharmacies use this system, with approximately 22 million patients using the service nationwide; over 934,226,838 items have been dispensed using EPS. In order to set you up on EPS, we need you to choose a nominated pharmacy where we will send your prescriptions. Some controlled drugs cannot be sent via EPS, if you are unsure if your medication will be sent EPS please check when ordering your medication. Don’t worry; you can change your pharmacy in the future by simply contacting the surgery and asking to change your prescription destination.

Nominated Pharmacy Name

Address Line 1

Town

County

Post Code

Carers – Do you look after someone who could not manage without you?

There is an estimated 6.5 million people in the UK who provide care for a partner, relative or close friend, some are officially registered as carers and may receive carers allowance, while there are many that don’t. We gather information about carers so we can help to deliver the best possible service.

I am a carer for someone

I have a carer, their details are below

Carers Details only complete this section if you have a carer.

Forename

Surname

Date of Birth

Relationship

Does the person hold legal power of attorney?

I want the person to be able to discuss;

Medication

Test Results

Referrals

Full Medical Record

I understand I have given consent for the above, named individual to have access to my medical records, to discuss those matters indicated above. I understand I can withdraw this consent at anytime but must provide written notification to the surgery for this to happen.

Consent

From time to time you may want someone to be able to discuss your medical records with us. This could be a partner, relative or close friend. Please consider this option carefully, as if you provide consent for a named person, they will be able to discuss elements of your medical care with us. If you would someone to be able to discuss your care with us, without us requiring additional consent, please provide their details below. For children aged 13 and younger, we will only discuss their care with people deemed to have parental responsibility unless otherwise stated. We reserve the right to refuse access to anyone other than the individual, the medical record pertains to if there are grounds that providing access is likely to cause serious physical or mental harm to the patient or the information you have asked for contains information that relates to a third person.

Forename

Surname

Date of Birth

Relationship

Does the person hold legal power of attorney?

I want the person to be able to discuss;

Medication

Test Results

Referrals

Full Medical Record

Past Medical History

Please provide details of any hospital treatment as an in-patient:

Please give details of any chronic medical conditions you have and any treatments received:

Please give dates of any X-ray, MRI or CT scans, Mammogram, Ultrasound:

Immunisations

Please provide the dates you received the following immunisations. If unknown please specify 'unknown'

Triple/Polio/HIB

MMR

Date of last Tetanus

Allergies

Do you have any allergies we need to be aware of? If you do please provide details with the entry.

Food Allergy

Drug Allergy

Pollen Allergy

Dust Allergy

Other Allergy

For Female Patients Only

Date of most recent cervical smear

Result most recent cervical smear

Are you currently pregnant?

Lifestyle

How often do you eat fruit or vegetables?

Do you usually have at least 30 minutes physical activity daily, either at work and/or during leisure time? (including normal activity)*

Smoking status:

If you would like help to stop smoking, please contact the local Quit Squad on 0800 328 6297.

Family History

Has any close relative suffered from the following, if they have please provide details.

Blood Pressure (hypertension)

Heart Attack

Angina

Diabetes

Stroke or TIA

Cancer

Kidney Disease

Alcohol Consumption

In brackets after each answer is a score for each answer option. Please note the score for each question and provide the total at the end.

How often do you have a drink containing alcohol?

How many units of alcohol do you drink on a typical day when you are drinking

How often had you had 6 or more units if female, or 8 or more if male, on a single occasion in the last year?

Total Score

Scoring: A total of 5+ indicates increasing or higher risk drinking. An overall total score of 5 or above is AUDIT-C positive

IF YOU SCORED 5 OR ABOVE ON THE ABOVE QUESTIONS PLEASE COMPLETE THE FOLLOWING QUESTIONS

In brackets after each answer is a score for each answer option. Please note the score for each question and provide the total at the end.

How often during the last year have you found that you were not able to stop drinking once you had started?

How often during the last year have you failed to do what was normally expected from you because of your drinking?

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?

Total Score

Scoring: 0-7 Lower risk, 8-15 Increasing risk, 16-19 Higher risk, 20+ Possible dependence

Thank you for completing your new patient questionnaire

Privacy Protection

Information submitted through secure forms is used only for the purposes of processing your request. We may be in touch with you in relation to the information submitted.

All Information submitted through secure forms is secured with a private key and is accessed over a secure connection by nominated staff. We have a strict confidentiality policy.

This information is not shared with any third party organisations.

This information is retained for up to 28 days.

I consent to my information being used for the purposes described above and wish to submit this online form to Buckshaw Village Surgery (BVS) • Buckshaw Village Health Centre, Unity Place, Buckshaw Village, Chorley, PR7 7HZ.

Learn more about our Privacy Policy and Terms of Use. Should you have any concerns about sending your personal details using the web, please use one of the alternative methods offered by our organisation.