Adult Registration Form

Your Contact Details
Title
Name*
First Names Surname
Previous Surnames
Date of Birth*
DD slash MM slash YYYY
Occupation
Town and country of birth*
Home Telephone*
Work Telephone
Mobile Telephone*
Home Address (inc. flat number if appropriate)*
Postcode*
Email address*
Please help us trace your previous medical records by providing the following information
Your previous address in UK
Name of previous GP practice while at that address
Address of previous GP practice while at that address
If you are from abroad
Your first UK address where registered with a GP
If previously resident in UK, date of leaving
Date you first came to live in the United Kingdom
Were you ever registered with an Armed Forces GP
Please indicate if you have served in the UK Armed Forces and/or been registered with a Ministry of Defence GP in the UK or overseas
- Regular
- Reservist
- Veteran
- Family Member (Spouse, Civil Partner, Service Child)
Address before enlisting
Service or Personnel number
Postcode
Enlistment date
MM slash DD slash YYYY
Discharge date (if applicable)
MM slash DD slash YYYY
NHS Organ & Blood Donation
Organ Donation has become an automatic enrolment since 20 May 2020. If you wish to opt out please go to https://www.organdonation.nhs.uk/helping-you-to-decide/about-your-choices/ to record your decision.
If you would like to become a NHS Blood Donor please register at https://www.blood.co.uk/
Information About You
What is your height?*
What is your weight?*
What is your first language?*
Do you need an interpreter?*
- Yes
- No
Ethnicity*
- White British
- White Irish
- Black Carribbean
- Black African
- Asian Indian
- Asian Pakistani
- Asian Chinese
- White + Black Carribbean
- White + Black African
- White + Asian

Smoking
Do you smoke?*
- Yes
- No
Have you ever smoked?*
- Yes
- No
How many cigarettes or ounces of tobacco do you smoke per week?
Would you like advice on giving up smoking?
- Yes
- No
Alcohol
1 drink = 1/2 pint of beer OR 1 glass of wine OR 1 single spirit
How often do you have drink containing alcohol?*
How many units of alcohol do you drink on a typical day when you are drinking?*
How often have you had 6 or more units if female, or 8 or more if male, on a single occasion in the last year?*
In the last year has a relative or friend, or a doctor or other health worker been concerned about your drinking or suggested you cut down?*
Would you like an appointment with our In-House CGL Advisor regarding your Alcohol use?
- Yes
- No

Family History
Please state any serious illness, in particular cancer, heart disease, stroke, high blood pressure, diabetes or any inherited disease. Please state your relationship to the individual and in the case of cancer, the type of cancer.
Next of Kin
Name*
First Last
Mobile Phone Number*
Relationship to you*
Is this person currently registered with us?*
- Yes
- No
- Don't know
For patients aged 65 and over or those with a chronic disease (e.g. asthma or diabetes)
Have you had a flu vaccination? If yes, please specify the date.
Have you had a pneumococcal vaccination? If yes, please specify the date.
Would you like to join our PPG?
- Yes
- No
Contacting You*
- I agree that I may be contacted from time to time, via email and/or SMS, with practice news, advice about my health and/or appointment reminders.
Signature
You will be asked to sign and date this form when you visit the practice.
Consent*
By submitting your details you are consenting to providing this information for improving our services to you. The data you supply on this form will be securely stored on our website, which is hosted by a third party. We will retain this information on the website for no longer than 7 calendar days. Your contact details will not be sold or shared with a third party. I understand I can revoke this consent at anytime by contacting the practice. Our privacy policy can be viewed on this website.
I agree to the privacy policy.

Step 1 of 5

Your Contact Details

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

If you are from abroad

Were you ever registered with an Armed Forces GP

NHS Organ & Blood Donation

Information About You

Proof of Identity and Address

Medical Information

Medical Information (continued)

Carers

Will

Women

Smoking

Alcohol

Family History

Next of Kin

For patients aged 65 and over or those with a chronic disease (e.g. asthma or diabetes)

Signature

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