New Patient Form

Which practice would you like to register with?

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Patient's Details

Please specify

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Last Name

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First name(s)

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Previous Last Name (s)

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NHS number

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Language Support

What is your main spoken language?

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Do you need an interpreter?

Yes No Invalid Input

Do you use any of the following?

Sign language BSL Hearing Aid Lip reading Invalid Input

Contact Details

Address Line 1

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Address Line 2

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Postcode

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Town

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County

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Email address

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Main telephone number

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Alternative telephone number

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Can we contact you by text?

Yes No Invalid Input

Can we contact you by email?

Yes No Invalid Input

What is your previous address and postcode?

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Please provide the details of your previous GP practice

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Emergency Contact

Name of your emergency contact

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What is their relationship to you?

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Telephone number of your emergency contact

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Carers

Do you regularly care for someone who has care needs due to a medical condition?

Yes No Invalid Input

What is their relationship to you?

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Do you have a carer?

Yes No Invalid Input

What is their relationship to you?

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Summary Care record:

There is a new Central NHS Computer System called the Summary Care Record (SCR). It is an electronic record which contains information about the medicines you take, allergies you suffer from and any bad reactions to medicines you have had.

Why do I need a Summary Care Record?

Storing information in one place makes it easier for healthcare staff to treat you in an emergency, or when your GP practice is closed. This information could make a difference to how a doctor decides to care for you, for example which medicines they choose to prescribe for you.

Who can see it?

Only healthcare staff involved in your care can see your Summary Care Record. If you wish to know more regarding the system and the benefits, please visit www.nhscarerecords.nhs.uk or call 0845 603 8510.

Would you like to opt in?

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Are you happy for us to share your full medical record electronically with other services involved in your care?

Yes No Invalid Input

How did you hear about us?

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Parents and Guardians

How many children do you have, or how many children are you responsible for full time?

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*Parents and guardians - If you would like to register a child with us, there are some important details we need from you. Once you have submitted this form, you will be redirected to the Child Registration Form.

Medical History

What is your height?

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What is your weight?

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Are you on any regular medication?

Yes No Invalid Input

Please list your medication

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Do you have any allergies?

Yes No Invalid Input

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

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Are you living with any of the below long term medical conditions?

Type 1 Diabetes

Yes No Invalid Input

Date of Diagnosis

/ / Invalid Input

Type 2 Diabetes

Yes No Invalid Input

Date of Diagnosis

/ / Invalid Input

High Blood Pressure

Yes No Invalid Input

Date of Diagnosis

/ / Invalid Input

Stroke/TIA

Yes No Invalid Input

Date of Diagnosis

/ / Invalid Input

COPD

Yes No Invalid Input

Date of Diagnosis

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Asthma

Yes No Invalid Input

Date of Diagnosis

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Heart Disease

Yes No Invalid Input

Date of Diagnosis

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Heart Failure

Yes No Invalid Input

Date of Diagnosis

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Do you have anything significant from your past medical history that we should know?

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Are you a:

Current Smoker Ex-Smoker Someone who has never smoked Invalid Input

If you are a current smoker, how many cigarettes do you smoke per day?

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Smoking can seriously damage your health and others around you. If you are thinking about giving up you can contact our reception team or the Southwark specialist stop smoking team on 0800 169 6002, and they can advise you how and where to get help.

How many units of alcohol do you drink per week?

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The following are 1 unit;
Half-pint of regular beer, cider or lager
1 very small glass of wine
1 single measure of spirit
1 small glass of sherry
1 single measure aperitifs

Please answer all of the questions below. If your answers are 3 or higher it indicates that you are at increased risk of harmful drinking. If you would like to discuss your drinking further, please book an appointment with a GP or Nurse.

How often have you had 8 (men)/6 (women) or more units on a single occasion?

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How often in the last year have you not been able to remember when drinking the night before?

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How often in the last year have you failed to do what was expected of you because of drinking?

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Has a relative or friend, doctor or other health worker been concerned about your drinking or suggested that you cut down?

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Sexual Health

Chlamydia and gonorrhoea:

Southwark has a higher than average rate of these infections, self-testing kits are available at the practice. Please ask at reception for more information.

HIV and other blood borne viruses:

Southwark has a higher than average rate of HIV and hepatitis; to get tested please ask at reception for details. Please note there is a local policy for routine HIV testing as part of standard blood tests.

Please state any vaccinations you have previously had

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Have you had your first dose of the Covid-19 vaccination?

Yes No Invalid Input

Date of Vaccine

/ / Invalid Input

Have you had your second dose of the Covid-19 vaccination?

Yes No Invalid Input

Date of Vaccine

/ / Invalid Input

Are you pregnant?

Yes No Invalid Input

If so, have you had vaccinations for whooping cough and flu?

Yes No Invalid Input

For people with a cervix aged 25-64: When was your last smear test/cervical screening?

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If your cervical screening test was done outside of England or Wales, please attach the result. If this cannot be done, please book an appointment for cervical screening with the nursing team at your registered practice.

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For those who have had a hysterectomy (removal of womb) please state the date

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For women aged 50 -71: When was your last mammogram?

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For those aged 60-74: When was your last bowel screening?

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NHS Health Check

If you are aged between 40 -75 years old and you are not known to have a pre-existing health condition (such as diabetes or heart disease) and are eligible for a free NHS health check in the last 5 years. If you do not have a pre-existing health condition, please book an appointment with a member of the nursing team.

Prescriptions

For repeat prescriptions, we use the NHS app for smartphones, or Patient Access online. You can also visit your local pharmacy who will arrange to have your prescription delivered directly to them. Please note that all prescriptions will be sent electronically to your nominated pharmacy.

Please name your preferred pharmacy where you would like to collect your prescriptions

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Patient Participation Group

Our PPGs are a mix of registered patients and practice staff who meet to discuss and make decisions about the organisation. It an opportunity for patients and service users to feed back about the services we offer.

Would you like to join our patient participation group?

Yes No Invalid Input

Register as a new patient

Patient's Details

Language Support

Contact Details

Emergency Contact

Carers

Summary Care record:

Why do I need a Summary Care Record?

Who can see it?

Parents and Guardians

Medical History

Sexual Health

Chlamydia and gonorrhoea:

HIV and other blood borne viruses:

NHS Health Check

Prescriptions

Patient Participation Group