2024 Whaddon Healthcare New Patient Registration Form

ANY SECTION UNFILLED MAY RESULT IN LATE REGISTRATION OR YOUR REGISTRATION MAY BE REJECTED. IF YOU ARE UNABLE TO FILL IN THIS ONLINE FORM OR SUBMIT MANDATORY INFORMATION, PLEASE ATTEND THE SURGERY IN PERSON AND COLLECT A PAPER REGISTRATION FORM.

 

Last Updated: 18/09/2024

ZERO TOLERANCE SCHEME

 If you have previously been de-registered under our zero-tolerance scheme you must not register with our practice without first writing to the Practice Manager with your request. If the practice declines your request to register, they will inform you in writing of the decision. The practice has a right to remove your registration at their discretion at any time if you have previously been removed from our list for abusive behavior and not informed them at the point of re-registering.

Patient's Details





















NEXT OF KIN





PATIENTS WHO ARE UNDER 16 YEARS OLD







CARE HOME RESIDENTS


COMMUNICATION








ONLINE SERVICES

We do recommend patients sign up for online services.

We request that patients provide identification when registering at the practice. If you’re unable to provide identification, we can still register you, however you won’t be able to access our online services without proof of identification.

Please provide photographic identification and proof of address to register with our online services.


PRESCRIPTIONS


SUMMARY CARE RECORD AND ACCESS

Your Summary Care Record is a short summary of your GP medical records. It tells other health and care staff who care for you about the medicines you take and your allergies.  It means they can give you better care if you need health care away from your usual doctor's surgery: for example, in an emergency, when you're on holiday, when your surgery is closed, at out-patient clinics or when you visit a pharmacy.



PERSONAL, MEDICAL AND CLINICAL HISTORY






FAMILY HISTORY


MEDICATION

If you are taking regular medication from your previous GP, you will need to book an appointment before our GP’s can issue this, please allow yourself plenty of time so you do not run out of medication and bring along any previous prescription requests / medication with you to the appointment.

 Please note we do not accept prescription requests over the phone




LEARNING DISABILITY





VETERANS



CARERS




HOMELESS

If you are homeless or at risk of homelessness, please complete the information below. The reason we ask for this information is so that we can send a referral to the local homelessness team.

Please be aware once the referral has been sent, the practice will be unable to provide you with further information regarding the referral. The homelessness team will contact you directly





SOCIAL SERVICES



EDUCATION




PATIENT HEALTH


HIV

HIV (Human Immunodeficiency Virus) is a virus which attacks the immune system - the body's defence against diseases. That is why it is so important to get tested and know your status, as with early diagnosis, free and effective treatment, most people with HIV will not develop any AIDS related illnesses and are likely to live a normal lifespan.


SMEAR TEST ELIGIBILITY


ALCOHOL





SMOKING CESSATION







CONSENT


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