Allesley Park Medical Centre New Patient Registration

Custom – Allesley Park Medical Centre

Practice Boundary

Do you live within our Practice Boundary? Please check HERE prior to completing this form. Registrations are only accepted if you currently live within our permitted area.

Please Note

If you do not live within our Practice Boundary, unfortunately, you will not be able to register at our practice. Please see NHS Choices for GPs in your area.

Your Details

Title

Please Note

When providing your name, please ensure this matches as identified on official documents such as your Birth Certificate, Passport or Visa. This will allow us to correctly identify you on the NHS system.

If Known
Gender
Is your gender the same as at birth
Which of the following best describes you?
Do you give us permission to communicate with you by text?
Please ensure that your email address is correct.
Do you give us permission to communicate with you by email?
Are you or the person you are registering aged 18 or under?
Is the patient currently in education?
Is the patient known to a health visitor?
Is the patient known to Social Services?
Have you previously been registered with a GP in the UK?

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

If you are from abroad

Ethnicity

Ethnic Group

Height and Weight

Weight

Unit of measurement *
cm
kg
ft
in
lbs

BMI

Underweight
Healthy
Overweight
Obese

Emergency Contact

Armed Forces

Are you returning from the armed forces?

Carers

Are you a Carer?

Medical History

Do you have any communication needs?
Do you have a long term condition?
Are you currently taking any medication?
Please note: If you are taking any medication, you will need to see a Doctor before you request a repeat prescription.

Do you have any of the allergies listed below?

Penicillin Allergy
Nut Allergy
Egg Allergy
Latex Allergy
Reaction to ibuprofen
Reaction to paracetamol
Hay Fever
Reaction to Amoxicillin
Allergy to Animal
Reaction to Ceporex

Smoking

Smoking Status
Would you like help to stop smoking?

Supplementary Questions

Are you ordinarily 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 select one of the following statements:

I declare that the information I give on this form is correct and complete. I understand that if it is not correct, appropriate action may be taken against me.

A parent/guardian should complete the form on behalf of a child under 16

Signed:

Summary Care Record

Summary Care Records Consent preference
Summary Care Records (SCR) are an electronic record of important patient information,created from GP medical records. They can be seen and used by authorised staff in other areas of the health and care system involved in the patient’s direct care.

Signed

I declare that the information I give on this form is correct and complete. I understand that if it is not correct, appropriate action may be taken against me.

A parent/guardian should complete the form on behalf of a child under 16