Practice
Patient Details
First Name(s)
Surname
Previous Surname
Date of Birth (dd/mm/yyyy)
Place of Birth
Ethnicity
White (UK) White (Irish) White (Other) Black Caribbean Black African Black Other Bangladeshi Indian Pakistani Chinese Other
Previous GP
NHS Number
Current Address
Previous Address
Previous Address
If you are from abroad
Country of Birth
Date of Arrival
Mobile
Home
Work
E-mail (Capitals)
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
Religion
Marital Status
Occupation
Next of Kin
Full Name
Relationship
Contact Number
Address
Allergies
If Yes - which medication(s), what happened, when this happened, how long you took the medication for and was it tablets or injection?
If Yes - what food(s), pollen or animal, what happened, and when?
Please tell us about your smoking habits (not needed for children)
How many do you smoke a day?
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.
Spoken language
Spoken language
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:
Consent
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