Application to Register Permanently with a General Medical Practice
This form must be completed as fully as possible.
1. Personal Details
2. Information to Help Trace Your Previous GP Health Records
3. If you are from abroad
4. If you have served in HM Armed Forces
New Patient Registration/Health Questionnaire
All information supplied will be recorded in your confidential medical records.
Contact Details Smoking Alcohol
For the following questions please answer to the best of your knowledge.
We have provided a basic guide to alcohol content below to assist your completion.
A 750ml bottle of wine contains 10 units.
A standard(175ml) glass of wine contains 2 units.
A single small shot of spirits (25ml) contains 1 unit.
A standard 70cl bottle of spirits contains 28 units.
A pint of 3.6% strength lager/beer/cider contains 2 units.
A pint of 5.2% strength lager/beer/cider contains 3 units.
How many units of alcohol do you drink a week? Height & Weight Next of Kin Family History Medication
Please give details of any medication which you take (prescribed or otherwise). Please enter each drug on a separate line.
Name of drug - Dosage Please add a photo of your most recent repeat medication slip if you have one. Allergies If Yes, please give details Past Medical History
Please give details of any treatments/medical conditions.
Carer Information History Special Circumstances
Please tick any/all that apply.
Military Veteran Communication
Do you have any communication / information needs relating to sensory loss and, if so, what are they and how would you like us to communicate with you?
We now need you to provide proof of your identification and your address. We ask for 2 things: Step 1
A photo of your passport or driving licence, as proof of your name;
A photo of a recent utility bill or similar, from sometime over the past 3 months, as proof of your current address.
Please note that we use these items once for verification when setting up your account, and we delete them as soon as your account is open.