New Patient Registration and Health Questionnaire

Patient’s Details

Title *
Please use this date format: DD/MM/YYYY.
What is your sex as recorded on your NHS record? *
Do you know your NHS number?
Town and country of birth
Any responses we send will go to this email address.
Can we contact you by text? *
Can we contact you by email? *

Previous Details

Please include postcode.
Are you registering with a UK GP for the first time?
Have you been registered here previously?

If you are from abroad

Please use this date format: DD/MM/YYYY.
Are you returning from overseas?

If you are returning from abroad

Please use this date format: DD/MM/YYYY.
Please use this date format: DD/MM/YYYY.

Emergency contact

Do you have an emergency contact?
Do you give us permission to discuss your medical records with them? *

Next of Kin

Do you give us permission to discuss your medical records with them?

Armed Forces

Have you ever been a member of the UK Armed Forces or are a family member registered with the Defence Medical Services?
If applicable

Special Circumstances

Please tick if any of the following apply:

Carers

Do you give us permission to discuss your medical record with your carer?

Allergies

Do you have any allergies?

Disability

Are you:

Ethnicity

Please specify the ethnic group you consider you belong to: *
Do you speak English?
Do you read English?
Do you need a language interpreter?
Includes British Sign Language