New Patient Questionnaire - Adult

You will also need to complete the Patient Registration Form to register at the practice. Please allow 5 working days for registration - you will not receive confirmation of registration.

Last Updated: 19/05/2021

Your Details

Full Name *

Date of Birth *

Home Phone Number

Mobile Phone Number *

Work Phone Number

Email Address *

Contacting You

Do you consent to receiving SMS messages? Please note: The practice’s preferred method of recall is by letter, and when appropriate, by text *

Yes No

Next of Kin

Full Name *

Address and Telephone Number

Relationship To Me

Information About You

Communication Needs

Carers

* Only add carer’s details if they give their consent to have these details stored on your medical record

Are you a carer? *

Yes – Informal or Unpaid Carer

Yes – Occupational or Paid Carer

Do you have a carer? *

Yes No

Name, Address, Telephone Number and Relationship of carer or person being cared for

Medical Information

Alcohol

Smoking

Height and Weight

Height (m)

Weight (kg)

Women

Do you use any contraception? If needed, please book appointment *

Yes No

Are you currently pregnant or think you may be?

Yes No

If yes, expected due date

Sharing Your Health Record

Your Health Record: Do you consent to your GP Practice sharing your health record with other organisations who care for you? *

Yes No

Your Health Record: Do you consent to your GP Practice viewing your health record from other organisations that care for you? *

Yes No

Your Summary Care Record (SCR): Do you consent to having an Enhanced Summary Care Record with additional information? *

Yes No

Online Access

To enable you to register for online services please provide; Photographic ID e.g. passport or driving licence

I wish to have online access to: Please tick all that apply *

View and book appointments

View and request medication

Access my coded medical record (contains any medical codes that have been recorded)

Access my full medical record (contains medical codes and any free text that has been recorded)

Access my Summary Care Record

I consent to my username and password for online access being sent to me by SMS, email or post

Yes No

Signature

I confirm that the information I have provided is true to the best of my knowledge.

Signed on behalf of patient

Yes

Signature *

Date *

This form is protected by reCAPTCHA and the Google Privacy Policy and Terms of Service apply.

Cookies on the The Beacon Health Group website

New Patient Questionnaire - Adult

Further Information