New Patient Registration - Welcome to Lordswood Medical Group

Which Practice would you like to register for?

Lordswood House Selcroft Medical Practice Quinton Family Practice

Date of Birth (dd/mm/yyyy)

If you are from abroad

Are you new to the UK

Yes No

Do you consent to receiving SMS messages and being contacted by Phone/mobile

Yes No

Do you consent to receiving SMS messages and being contacted by Letter

Yes No

Do you consent to receiving SMS messages and being contacted by Email

Yes No

As part of our digital communication, we may wish to contact you about your reviews, either by Mobile Messaging or E-Mails. Please be aware not to share these details, if you wish the messages to be confidential.

Additional Details about You

Are you allergic to any medicines?

Yes No

If Yes - which medication(s), what happened, when this happened, how long you took the medication for and was it tablets or injection?

Do you have any pollen, animal hair, nut, seafood or other food allergy?

Yes No

If Yes - what food(s), pollen or animal, what happened, and when?

Please tell us about your smoking habits (not needed for children)

Do you smoke?

Yes No

If Yes, What do you primarily smoke

How many do you smoke a day?

Would you like advice on quitting?

Yes No

Are you an ex-smoker?

Yes No

Medical Details: In order to continue to receive your repeat medications you’ll need to bring in your re-order form from your previous GP.

Vaccinations: Please bring in the Red Book of the child to update their vaccination history. If in case you do not have the Red Book please bring in a copy of the vaccinations had from your previous GP.

Additional Details

Accessible Information Standard
We would like to get better at communicating with our patients. We want to make sure that you can read and understand the information we send you. If you find it hard to read our letters or if you need someone to support you at appointments, please let us know. We want to know if you need information in braille, large print or easy read. We want to know if you need an interpreter for your appointments.

Do you have any communication needs?

Yes No

What type of communication needs?

Registered partially blind Registered blind Deafness Hearing loss

Do you need a format other than standard print?

Require written information in large font Require information in uncontracted Braille Require information in contracted Braille

Do you have any special communication requirements?

English speaker

Yes No

Interpreter needed

Yes No

If yes what language

Nominated Pharmacy

We have electronic prescribing functionality, this will allow us to send your prescription electronically to your preferred choice of pharmacy, and will also save you time in collecting your prescription from the surgery. Your Nominated pharmacy at Lordswood will be: Knights Pharmacy (next door to the surgery) Your Nominated pharmacy at Selcroft will be: Selcroft Pharmacy (next door to the surgery) Your Nominated pharmacy at Quinton Family will be: Rajja Pharmacy (5 Dwellings Lane)

If you would like to use another Pharmacy, please give the name and address:

Are you happy for authorised healthcare staff to view your medical record when you recieve direct patient care?

Yes No

I declare that the information provided on this form is correct to the best of my knowledge

Yes

I declare consent to being contacted via the details given above. I agree to the privacy policy that the information provided on this form is correct to the best of my knowledge

Yes

To view our privacy policy, click here

New Patient Registration Form

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