New Patient Registration Form - Clerkenwell Medical Practice

Please complete the New Patient Registration form found below.

It takes up to 10 working days to process your registration. To avoid delays, please provide all the information requested – otherwise our admin team will have to contact you for queries or missing information – together with all up-to-date contact details.

Once your registration is complete, you will become a registered patient at Clerkenwell Medical Practice and will be able to access our full range of services that include completing a website eConsult for the doctor, booking an appointment with a member of our team and requesting your repeat medication. Please note: should you have an urgent health issue that really cannot wait and you believe needs to be dealt with urgently, please contact a member of our admin team who will be able to help if your registration is still being processed.

Personal Details

Title

NHS Number (if known) Optional

You can find your NHS number on the NHS APP, medical emails or letters etc.

First Names

Surname

Previous Surname Optional

Date of Birth

Day

Month

Year

Town & Country of Birth

Telephone Number

Email Optional

Current Address

Street Address Address Line 2 City Postcode

Demographics

Ethnicity

Marital Status

Main Religion Optional

Sex and gender identity – Which one of the following best describes how you think of yourself?

Is your gender identity the same as the gender you were given at birth?

Which of the following options best describes you?

Do you have a previous address in the UK?

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

Your previous address in the UK

Street Address Address Line 2 City Postcode

Name of doctor while at that address Optional

Address of previous doctor

Street Address Optional Address Line 2 Optional City Optional ZIP / Postal Code Optional

If you are from abroad

Are you from abroad?

Yes

Your first UK address where registered with a GP

Street Address Optional Address Line 2 Optional City Optional Postcode Optional

Previous UK residents

Are you a previous resident in the UK?

Yes

If previously resident in UK, date of leaving

Day Optional

Month Optional

Year Optional

Date you first came to live in the UK

Day Optional

Month Optional

Year Optional

European Economic Area (EEA) Country

For a list of EEA countries visit: www.gov.uk/eu-eea

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 Optional

No Optional

Communication Needs

What is your main spoken Language?

What is your main spoken language?

Disability

Do you have an impairment, health condition, or learning difference that significantly affects your ability to perform daily activities for over a year? Optional

Do you have any specific information or communication needs? (e.g. large print, Braille, easy read communications) Optional

Please provide details on how we can fulfill these requirements for you. Optional

Armed Forces

Have you served in the UK Armed Forces and/or been registered with a Ministry of Defence GP in the UK or overseas?

Yes

Do you have access to secure housing?

Yes

What is your current immigration status?

Asylum Seeker Optional

Failed Asylum Seeker Optional

Carers

Do you have a carer?

Do you have caring responsibilities? Optional

Emergency Contact

Full Name

Contact Number

Relationship to you

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

Yes

Are they your next of kin?

Yes

Additional Health Information

Height

Please specify units, e.g., feet/inches or meters/centimeters

Weight

Please specify units, e.g., pounds or kilograms

Smoking Status

What do you smoke?

e.g. Cigarettes, Vape, Cigars

How many do you smoke per day?

Are you interested in advice on how to quit? Optional

How much exercise do you engage in per week?

Type of Exercise:

What other types of exercise do you engage in? Optional

Alcohol Consumption

For more information and calculations of Alcohol Units visit: https://www.nhs.uk/live-well/alcohol-advice/calculating-alcohol-units/

How often do you have a drink containing alcohol?

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

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

Medical History

Please provide as much information as possible about your medical history.

Do you have any significant medical history that we should be aware of? Optional

Medical History Optional

Do major illnesses run in your family? If so, which ones? Optional

Have you had any major surgeries? Please list them with dates. Optional

Are you currently taking any medications? If yes, please list them. Optional

We regularly provide HIV screening. Would you like to be screened?

How would you rate your eyesight?

How would you describe your hearing ability?

Are you over 75 years old?

The Department of Health has advised that all patients of 75 years and older have a named and accountable GP to oversee their care.

Please ask the name of the GP assigned to oversee your care.

Please note this does not prevent you from seeing the GP of your choice.

Allergies

Do you have any allergies?

Yes

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

Immunisation History

Have you been previously vaccinated or immunised?

Please provide a list of any immunizations or vaccinations you have received. Optional

Please include dates

Important Registration Information

For anyone aged 16 and over, we offer online services for appointment booking and repeat prescription ordering. This is the quickest and easiest way to order your medication. Once registered, you will also be able to view your summary record, detailing current medication, allergies and vaccinations.

You will soon receive an email from the practice with your log in details.

These are confidential: It is your responsibility to ensure they can be received securely by email.

Prescriptions are sent electronically to your nominated pharmacy. We will automatically nominate the pharmacy closest to your post code as part of your registration. If you prefer to use a different chemist please contact the practice to sign up for the Electronic Prescribing Service

Summary Care Record

This record will contain summary information about any medicines you are taking, allergies you suffer from and any bad reactions to medicines you have had to ensure those caring for you have enough information to treat you safely.

Your Summary Care Record will be available to authorised healthcare staff providing you with care anywhere in England, but they will ask your permission before they look at it. This means that if you have an accident or become ill away from home, healthcare staff treating you will have immediate access to important information about your health.

Do you consent to having a Summary Care Record?

Yes

Your Medical Information – Sharing Your Data

Under the General Data Protection Regulations (GDPR), we have a responsibility to keep your medical records confidential. We need your consent to share this with other authorised health professionals involved in your care or in planning your care. You can find more information on the website at www.nhs.uk/your-nhs-data-matters.

Please see the privacy notice on our website for more information on how your data is held and used by the practice.

The NHS wants to make sure you and your family has the best care now and in the future. Your health and adult social care information supports your individual care. It also helps us to research, plan and improve health and care services in England.

There are very strict rules on how this data can and cannot be used, and you have clear data rights. We are committed to keeping patient information safe and will always be clear on how it is used.

You can choose whether or not your confidential patient information is used for research and planning.

If you do not wish your information to be used in this way please opt-out by visiting NHS: Your Data Matters or by calling 0300 303 5678. The practice is unable to record this for you.

NHS Organ Donor registration

For more information on organ donation please visit: www.organdonation.nhs.uk

NHS Blood Donor registration

If you would like to join the NHS Blood Donor Register as someone who may be contacted and would be prepared to donate blood, please visit their website on: www.blood.co.uk or call direct on 03001232323

What happens to my information?

Personal and medical information about patients registered at this practice are primarily kept electronically, although some is kept in paper form. Some information will be sent to hospital consultants and other health professionals to whom you are referred by your GP in order to provide continued healthcare and obtain treatment for you.

We sometimes use accredited suppliers for our communication with you, for example when we send recall letters for review clinics or medication reviews. All suppliers we use are checked carefully to ensure they comply with strict confidentiality protocols.

To ensure the security of all patient information, all staff that has access to your records is covered by confidentiality clauses in their contracts and the Data Protection Act and the Freedom of Information Act. Our guiding principle is that we hold your records in strict confidence.

Signature

Declaration

I certify that the information I have provided is correct and consent to my personal and medical information being used as stated above. Optional

Signature

Your Full Name

Date

Day

Month

Year