New Patient Registration

If you would like to register with the practice please use this form.

To register a new patient you will need to live within our practice boundary.

New Patient Registration - FMC

Personal Details

Title: *
Are you an asylum seeker: *

Demographics

Which of the following options best describes your gender? *
Which of the following options best describes your sexuality? *
Is your gender identity the same as the gender you were given at birth? *
Would you like to access a free New Patient check at the practice? *
In Feet/Inches
In Stones/lbs
Your Religion: *
Your Ethnic Origin: *
Your main or 1st language spoke/understood (select one): *

Smoking, Alcohol Consumption and Exercise

Are you currently a smoker?
Have you ever been a smoker?

If you are a smoker and want to stop, please ask for information about local smoking cessation services.

Please state the number of times per week.
Are there any serious diseases that affect your Parents, Brothers or Sisters (tick all that apply):

This is one unit of alcohol:

Amount of different types of drink representing one unit of alcohol

And each one of these, is more than one unit:

Amount of different types of drink representing more than one unit of alcohol
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 have you had 6 or more units if female, or 8 or more if male, on a single occasion in the last year? *

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? *

Summary Care Record

This information is not available to anyone else and is only viewable by NHS services. The NHS are changing the way your health information is stored and managed.

The NHS Summary Care record is an electronic record of important information about your health that will be available to other services such as A&E and BARDOC.

You may tick the ‘allow additional information to be viewed’ which will allow things like language spoken, serious health issues, etc to be shared with these services.

Are you happy to have a Summary Care Record? *
Do you allow additional information to be viewed? *

Accessible Information Standards

Please tick any of the listed methods of contact that you do not wish for us to use:
Do you require to receive the information in any specific format?
Do you require any communication support for your appointments?
Are you an 'Assistance Dog' user?

Patient Participation Group

The Practice is committed to improving the services we provide to our patients. To do this, it is vital that we hear from people about their experiences, views, and ideas for making services better.

By expressing your interest, you will be helping us to plan ways of involving patients that suit you.
It will also mean we can keep you informed of opportunities to give your views and up to date with developments within the Practice.

If you are interested in getting involved, please tick the box below and we will arrange for the Practice Patient Participation Group Application Form to be given to you at your initial consultation.

Are you interested in becoming involved in the Practice Patient Participation Group? *

Declaration

*