Forms

Order your prescriptions

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Name*

First Last

Date of Birth*

Day

Month

Year

Telephone*

If there are any problems with issuing your prescription, we may call you to let you know.

Medications required*

Contact Us

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Comments

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Name*

Telephone

Email*

Message*

Registration Form - Adult (16+)

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Step 1 of 13

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Patient details

Name*

Please write this in English if applicable

Title First Name Surname Known as

Date of Birth*

DD slash MM slash YYYY

Birth Town*

Birth Country*

Sex at Birth*

Male

Female

NHS Number

If you need a doctor to dispense medicines and appliances

Nearest Chemist

I live more than 1 mile in a straight line from the nearest chemist

Chemist Difficulty

I would have serious difficulty in getting them from a chemist

Address*

Street Address Address Line 2 Town County Postcode Country

Home Phone Number

Do you consent to us leaving messages on this number?

Yes

Mobile*

Do you consent to receiving text messages to this number?*

Yes

Do you consent to us leaving messages on this number?*

Yes

Email Address

Do you consent to receive emails to this address?

Yes

Marital Status

GMS1 - Please help us trace your previous medical records by providing the following information

Previous Address in the UK*

Street Address Address Line 2 Town County Postcode Country

Have you previously been registered with an NHS GP in UK?*

Yes

Name of Previous GP*

Address of Previous GP*

Street Address Address Line 2 Town County Postcode Country

If you are from abroad

Registering with the NHS for the first time in the UK

Date you came to live in the UK

DD slash MM slash YYYY

If you are returning from abroad

Previously been registered with the NHS in the UK

Date you left the UK

DD slash MM slash YYYY

Date you returned to the UK

DD slash MM slash YYYY

Armed Forces

Please indicate if you have ever served in the UK Armed Forces*

Yes

Please indicate if you have ever served in the UK Armed Forces and/or been registered with a Ministry of Defence GP in the UK or overseas

Regular

Reservist

Family Member

Address before enlisting

Street Address Address Line 2 Town County Postcode Country

Service or Personnel Number

Enlistment Date

DD slash MM slash YYYY

Discharge Date

DD slash MM slash YYYY

Emergency Contact / Next of Kin

Name

Prefix First Last

Contact Number

Home Address

Relationship to Patient

Are they your next of kin?

Yes

Do you give us permission to contact them in an emergency?

Yes

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

Yes

Health History

Height (cm)*

Weight (kg)*

Blood Pressure Systolic Reading:

Please ask the receptionist to show you how to use our blood pressure monitor

Blood Pressure Diastolic Reading:

Pulse

Alcohol Consumption

How often do you have a drink containing alcohol?*

Never

Monthly or less

2-4 times per month

2-3 times per week

4+ times per week

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

1-2

3-4

5-6

7-9

10+

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

Never

Less than monthly

Monthly

Weekly

Daily or almost daily

Smoking

Smoker Status*

Current Smoker

Ex-smoker

Never Smoked

How many do you smoke per day?

How many did you smoke per day?

When did you stop?

Are you interested in advice on how to quit?

Yes

Exercise

How often do you exercise?*

Avoid even trivial exercise

Enjoys light exercise

Enjoys moderate exercise

Enjoys heavy exercise

Allergies

Do you have allergies?*

Yes

Please specify what you are allergic to, what happens and when you had your first reaction:

Medical History

Do you have any significant past medical history? (please include all pregnancies)

Regular Medication

If you are taking regular medication, please provide the surgery with your repeat medication request slip (from your previous surgery) so that the doctors may assess your condition(s) and prescribe for you. Please note we are unable to prescribe any repeat medication until you have seen a doctor at the surgery.

Please list current medication

Press the + button to add another medication

Family History

Please select the condition(s) that any family member has or had:*

Diabetes

High Blood Pressure

Heart Disease

Chronic Obstructive Pulmonary Disease

Cancer

Kidney Disease

N/A

For each condition please specify the condition and the family member affected:

Are you currently pregnant?*

Yes

Carers

Do you look after someone that could not manage without you?

Yes

Name of person you care for:

Relationship to you:

Are you being cared for by a relative, friend or child?

Yes

Name of carer who cares for you:

Relationship to you:

Communication Needs

Do you have any communication needs?*

Visual impairment, hearing difficulty, learning disability

Yes

Please give details

Please state how we can help you:

Patient Participation Group

What is a Patient Participation Group (PPG)? A group of registered patients and practice staff who meet frequently to discuss and make decisions about the practice and how it is able to service the community with improved healthcare services and facilities.

Would you be interested in joining our Patient Participation Group?*

Yes

Do you consent to us passing your name and contact details to the chairperson of the Patient Participation Group?*

Yes

Ethnicity

The Department of Health require us to record the ethnicity and language of every patient registered with the practice. This information will be used to help plan and deliver services appropriate to different communities. The categories below have been used across government since 2001 are taken from the Department of Health's website.

First Language*

If English is not your first language, do you speak English?*

Yes

Please specify which ethnic group you belong to:*

Summary Care Record

You have the choice of what information you would like to share and with whom. Authorised healthcare staff can only view your SCR with your permission. The information shared will solely be used for the benefit of your care.

Dear Patient,

If you are registered with a GP practice in England, you will already have a Summary Care Record (SCR), unless you have previously chosen not to have one. It will contain key information about the medicines you are taking, allergies you suffer from and any adverse reactions to medicines you have had in the past.

Information about your healthcare may not be routinely shared across different healthcare organisations and systems. You may need to be treated by health and care professionals who do not know your medical history. Essential details about your healthcare can be difficult to remember, particularly when you are unwell or have complex care needs.

Having a Summary Care Record can help by providing healthcare staff treating you with vital information from your health record. This will help the staff involved in your care make better and safer decisions about how best to treat you.

You have a choice

Your options are outlined below:

Express consent for medication, allergies and adverse reactions only. You wish to share information about medication, allergies for adverse reactions only.
Express consent for medication, allergies, adverse reactions and additional information. You wish to share information about medication, allergies for adverse reactions and further medical information that includes: your illnesses and health problems, operations and vaccinations you have had in the past, how you would like to be treated (such as where you would prefer to receive care), what support you might need and who should be contacted for more information about you.
Express dissent for Summary Care Record (opt out). Select this option, if you DO NOT want any information shared with other healthcare professionals involved in your care.

If you chose not to complete this consent form, a core Summary Care Record (SCR) will be created for you, which will contain only medications, allergies and adverse reactions.

Once you have completed the consent form, please return it to your GP practice.

You are free to change your decision at any time by informing your GP practice

Summary Care Record patient consent form

Having read the above information regarding your choices, please choose one of the options below and return the completed form to your GP practice :

Would you like your Summary Care Record?*

Yes - Express consent for medication, allergies and adverse reactions only.

Yes - Express consent for medication, allergies, adverse reactions and additional information.

No - I would not like a Summary Care Record (opt out).

Supplementary Questions

These questions and the patient declaration are optional and your answers will not affect your entitlement to register or receive services from your GP.

I am ordinarily a resident in the UK

I am not ordinarily a resident in the UK

Only complete the below if you have ticked 'I am not ordinarily a resident in the UK'.

Anybody in England can register with a GP practice and receive free medical care from that practice.

However, if you are not ‘ordinarily resident’ in the UK you may have to pay for NHS treatment outside of the GP practice. Being ordinarily resident broadly means living lawfully in the UK on a properly settled basis for the time being. In most cases, nationals of countries outside the European Economic Area must also have the status of ‘indefinite leave to remain’ in the UK.

Some services, such as diagnostic tests of suspected infectious diseases and any treatment of those diseases are free of charge to all people, while some groups who are not ordinarily resident here are exempt from all treatment charges.

More information on ordinary residence, exemptions and paying for NHS services can be found in the Visitor and Migrant patient leaflet, available from your GP practice. Alternatively for more information go to www.nhs.uk/visitingengland.

You may be asked to provide proof of entitlement in order to receive free NHS treatment outside of the GP practice, otherwise you may be charged for your treatment. Even if you have to pay for a service, you will always be provided with any immediately necessary or urgent treatment, regardless of advance payment.

The information you give on this form will be used to assist in identifying your chargeable status, and may be shared, including with NHS secondary care organisations (e.g. hospitals) and NHS Digital, for the purposes of validation, invoicing and cost recovery. You may be contacted on behalf of the NHS to confirm any details you have provided.

Please tick one of the following boxes:*

I understand that I may need to pay for NHS treatment outside of the GP practice.

I understand I have a valid exemption from paying for NHS treatment outside of the GP practice. This includes for example, an EHIC, or payment of the Immigration Health Charge ("the Surcharge"), when accompanied by a valid visa. I can provide documents to support this when requested.

I do not know my chargeable status.

European Economic Area (EEA) Country

Complete this section f you live in another EEA country, or have moved to the UK to study or retire, or if you lice in the UK but work in another EEA member state. Do not complete this section if you have an EHIC issued by the UK.

Do you live in another EEA country, or have moved to the UK to study or retire, or live in the UK but work in another EEA member state?*

Yes

Do you have a non-UK European Health Insurance Card (EHIC) or a Provisional Replacement Certificate (PRC)?*

Yes

If yes, please enter details from your EHIC or PRC below:

Country Code

Name

First Last Given Names

Date of Birth

DD slash MM slash YYYY

Personal Identification Number

Identification number of the institution

Identification number of the card

Expiry Date

DD slash MM slash YYYY

PRC validity period from

DD slash MM slash YYYY

PRC validity period to

DD slash MM slash YYYY

Do you have an S1?

E.g. you are retiring to the UK or you have been posted here by your employer for work or you live in the UK but work in another EEA member state). Please give your S1 form to the practice staff.

Yes

How will your EHIC/PRC/S1 data be used?

By using your EHIC or PRC for NHS treatment costs your EHIC or PRC data and GP appointment data will be shared with NHS secondary care (hospitals) and NHS Digital solely for the purposes of cost recovery. Your clinical data will mot be shared in the cost recovery process.

Your EHIC, PRC or S1 information will be hared with The Department for Work and Pensions for the purpose of recovering your NHS costs from your home country.

Signatures

Signatures*

Patient's signature

Signature on behalf of patient

Electronic Signature (Type your full name here)*

By completing the section above, I hereby sign this form electronically

Signature

Consent*

I agree to the privacy policy.

Registration Form - U16

"*" indicates required fields

Step 1 of 13

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This field is for validation purposes and should be left unchanged.

Patient Details

Name*

Title Child's First Name Child's Surname

Child's Date of Birth*

DD slash MM slash YYYY

Child's Sex at Birth*

Male

Female

NHS Number

Child's Address*

Street Address Address Line 2 Town County Postcode Country

Who else lives in this household? Please tick all those that apply:

Mum

Dad

Step Parent

Parent's Partner

Grandparents

Brothers & Sisters

Foster Carer

Guardian

Other

Child's Town of Birth*

Child's Country of Birth*

Child/Guardian's Home Phone Number

Do you consent to us leaving messages about this child on this number?

Yes

Child/Guardian's Mobile Phone Number*

Do you consent to us leaving messages about this child on this number?*

Yes

Do you consent to receiving text messages about this child to this number?*

Yes

Who has parental responsibility for this child? Please tell us their name, contact details and their relationship to the child:*

If this child is from abroad

Registering with the NHS for the first time in the UK

Date child came to live in the UK

DD slash MM slash YYYY

If this child is returning from abroad

Previously been registered with the NHS in the UK

Date child left the UK

DD slash MM slash YYYY

Date child returned to the UK

DD slash MM slash YYYY

GMS1 - Previous Details

Name of Previous GP

Address of Previous GP

Street Address Address Line 2 Town County Postcode Country

Health History

Has your child had any serious illnesses or operations?

Yes

What was this and when?

Does your child have a disability or chronic condition?

Yes

Medication

Is your child on any regular medication?

Yes

Please list current medication:

If you have a list from your previous GP please hand in a copy to any of our sites

Is you child allergic to any medication?

Yes

Please state which medication and when the reaction was (if known):

Further Information

Does your child have contact with any of the following?

A hospital specialist?*

Yes

A health visitor?*

Yes

A social worker?*

Yes

Any other health professionals?*

Yes

Has your child ever been under a Child Protection Plan?*

Yes

What is your child's main language?*

Do they need an interpreter or sign language support?*

Yes

Please specify the ethnic group you consider your child belongs to:*

White British

White Irish

Black Caribbean

Black African

Black Caribbean and White

Black African White

Indian

Pakistani

Bangladeshi

I do not wish to state

Other ethnic group

Immunisations

It is important that your child’s immunisations are kept up to date. A current photocopy of the immunisation history will help us to maintain their immunisation record; we can take a photocopy of this at reception. If this is not available then please list them below.

Is your child up to date with their vaccinations?*

Yes

If known please list the Immunisations your child has had and when

Summary Care Record

Dear Patient,

You have a choice

Your options are outlined below:

Express consent for medication, allergies and adverse reactions only. You wish to share information about medication, allergies for adverse reactions only.
Express consent for medication, allergies, adverse reactions and additional information. You wish to share information about medication, allergies for adverse reactions and further medical information that includes: your illnesses and health problems, operations and vaccinations you have had in the past, how you would like to be treated (such as where you would prefer to receive care), what support you might need and who should be contacted for more information about you.
Express dissent for Summary Care Record (opt out). Select this option, if you DO NOT want any information shared with other healthcare professionals involved in your care.

If you chose not to complete this consent form, a core Summary Care Record (SCR) will be created for you, which will contain only medications, allergies and adverse reactions.

Once you have completed the consent form, please return it to your GP practice.

You are free to change your decision at any time by informing your GP practice

Summary Care Record patient consent form

Having read the above information regarding your choices, please choose one of the options below and return the completed form to your GP practice :

Would you like your Summary Care Record?*

Yes - Express consent for medication, allergies and adverse reactions only.

Yes - Express consent for medication, allergies, adverse reactions and additional information.

No - I would not like a Summary Care Record (opt out).

Supplementary Questions

These questions and the patient declaration are optional and your answers will not affect your entitlement to register or receive services from your GP.

I am ordinarily a resident in the UK

I am not ordinarily a resident in the UK

Only complete the below if you have ticked 'I am not ordinarily a resident in the UK'.

Anybody in England can register with a GP practice and receive free medical care from that practice.

Please tick one of the following boxes:*

I understand that I may need to pay for NHS treatment outside of the GP practice.

I do not know my chargeable status.

European Economic Area (EEA) Country

Do you live in another EEA country, or have moved to the UK to study or retire, or live in the UK but work in another EEA member state?*

Yes

Do you have a non-UK European Health Insurance Card (EHIC) or a Provisional Replacement Certificate (PRC)?*

Yes

If yes, please enter details from your EHIC or PRC below:

Country Code

Name

First Last Given Names

Date of Birth

DD slash MM slash YYYY

Personal Identification Number

Identification number of the institution

Identification number of the card

Expiry Date

MM slash DD slash YYYY

PRC validity period from

DD slash MM slash YYYY

PRC validity period to

DD slash MM slash YYYY

Do you have an S1?

E.g. you are retiring to the UK or you have been posted here by your employer for work or you live in the UK but work in another EEA member state). Please give your S1 form to the practice staff.

Yes

How will your EHIC/PRC/S1 data be used?

Your EHIC, PRC or S1 information will be hared with The Department for Work and Pensions for the purpose of recovering your NHS costs from your home country.

Signatures

Name of parent or guardian submitting this form*

Title First Name Surname

Date of Birth*

DD slash MM slash YYYY

Signature*

Patient Participation Enrolment

"*" indicates required fields

Phone

This field is for validation purposes and should be left unchanged.

Name*

First Last

Date of Birth*

Day

Month

Year

Address*

Telephone (home)

Telephone (mobile)

Friends & Family Test

"*" indicates required fields

Facebook

This field is for validation purposes and should be left unchanged.

We would like you to think about your recent experiences of our service.

Thinking about your recent visit, overall, how was your experience of our service?*

Very good

Good

Neither good nor poor

Poor

Very poor

Don't know

Please can you tell us why you gave your answer?

New Patients: How do I register?

Prescriptions

Patient Participation Group

Friends & Family Test

Update your details

Patient access to health records

Purple Star Accredited Surgery Supporting Patients with Learning Disabilities

Opening Times / When closed please call 111

Monday08:00am to 06:30pm
Extended hours 18:30-20:00
Tuesday08:00am to 06:30pm
Extended hours 18:30-20:00
Wednesday08:00am to 06:30pm
Extended hours 18:30-20:00
Thursday08:00am to 06:30pm
Extended hours 18:30-20:00
Friday08:00am to 06:30pm
Extended hours 18:30-20:00
SaturdayCLOSED
SundayCLOSED

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Suthergrey House Medical Centre

Forms

Order your prescriptions

Contact Us

Registration Form - Adult (16+)

Patient details

If you need a doctor to dispense medicines and appliances

GMS1 - Please help us trace your previous medical records by providing the following information

If you are from abroad

If you are returning from abroad

Armed Forces

Emergency Contact / Next of Kin

Health History

Alcohol Consumption

Smoking

Exercise

Allergies

Medical History

Regular Medication

Family History

Carers

Communication Needs

Patient Participation Group

Ethnicity

Summary Care Record

Supplementary Questions

European Economic Area (EEA) Country

Signatures

Registration Form - U16

Patient Details

If this child is from abroad

If this child is returning from abroad

GMS1 - Previous Details

Health History

Medication

Further Information

Immunisations

Summary Care Record

Supplementary Questions

European Economic Area (EEA) Country

Signatures

Patient Participation Enrolment

Friends & Family Test

Opening Times / When closed please call 111

Useful Links

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