New Patient Registration Form

Provide the details below to register with the Practice. A member of staff may need to telephone you to confirm certain aspects of your Registration.

Full Name (inc Title)

Any Previous Last Names

Gender

Preferred Pronouns

Is your gender the same as the sex you were registered at birth?

Date of Birth

Place of birth (town & country)

Address and Post Code

Home Telephone Number

Mobile Telephone Number

Email Address

Do you consent to being contacted by

Text

Telephone

Previous Address

Name and Address of your previous GP

Next of Kin Full Name

Next Of Kin Relationship

Next of Kin Contact Number

Military

Are you a Military Veteran

Are you a member of a Military Family (Spouse or Deptendant Child)

If you have recently left the Armed Forces - Date of Enlistment

Date of Discharge

If you are From Abroad

If previoulsy resident in the UK the Date of leaving

Date first came to the UK

Communication Requirements

Do you have any special communication requirements?

If yes please state

Do you have a Learning Disability

Ethnicity / Language

What is your ethnicity?

Main Spoken Language

Medical History

Do you have any ongoing medical conditions? If so please list below with the date of diagnosis

Please list any medications and doses that you are currently taking

Name of the Pharmacy that you would like your presciptions to be sent to

Do you have any allergies?

How tall are you?

What is your current weight?

Carers

Are you a Carer?

Do you have a carer?

If you have a carer please tell us the Name and Address of your carer

Are you happy for us to contact your carer about you?

Smoking

Do you smoke or are you an ex-smoker

Yes

Ex smoker

Never smoked

How many do you smoke per day

Family Medical History

Has either of your parents or any siblings had Angina or Heart Attack before the age of 60

Yes

Lifestyle Alcohol

How many units do you have 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?

How often in the last year have you found you were not able to stop drinking once you have started?

How often in the last year have you had a feeling of guilt or regret after drinking?

How often during the last year have you been unable to remember what happened the night before because you had been drinking?

Female Patients Only

Are you currently or think you may be pregnant?

Date of last cervical smear

Have you had a Total Abdominal Hysterectomy?

Data Sharing

As part of the NHS, our surgery aims to provide you with the highest quality of health care. To do this we must keep records about you, your health and the care we have provided or plan to provide to you. These records may include:

• Basic details about you such as address, telephone number, date of birth, next of kin

• Contact we have had with you such as clinical visits

• Notes and reports about your health

• Details and records about your treatment and care, including test results

• Relevant information from people who care for you and know you well such as health professionals and relatives

Everyone working for the NHS has a legal duty to keep information about you confidential. We have a duty to maintain full and accurate records of the care we provide to you.

Some information will be held centrally to be used for statistical purposes. In these instances we take strict measures to ensure that individual patients cannot be identified.

Data Sharing (continued)

You will automatically be opted in for your information to be shared with the Care and Health Information Exchange (CHIE).

If you would like to OPT OUT then the following link would need to be completed.

CHIE OPT OUT: https://careandhealthinformationexchange.org.uk/wp-content/uploads/2021/11/Request-to-opt-out-of-sharing-to-CHIE-Adults.pdf

Summary Care Record

NHS Organ Donation

NHS Blood Donor

I would like to join the NHS Blood Donor REgister as someone who may be contacted and would be prepared to donate blood

I have given blood in the last 3 years

Do you have a non UK EHIC or PRC

Please complete if you live in another EEA country, or have moved to the UK to study or retire, or if you live in the UK but work in another EEA member state.

If yes please enter the details from your EHIC or PRCIf you are visiting rom another EEA country and do not hold a current EHIC or PRC, you may be billed for the cost of any treatmnent received outside of the GP practice including at a hospital

Privacy Protection

Information submitted through secure forms is used only for the purposes of processing your request. We may be in touch with you in relation to the information submitted.

All Information submitted through secure forms is secured with a private key and is accessed over a secure connection by nominated staff. We have a strict confidentiality policy.

This information is not shared with any third party organisations.

This information is retained for up to 28 days.

I consent to my information being used for the purposes described above and wish to submit this online form to Solent View Medical Practice • Lee-on-the-Solent Health Centre, Manor Way, Lee-on-the-Solent , Hampshire , PO13 9JG.

Learn more about our Privacy Policy and Terms of Use. Should you have any concerns about sending your personal details using the web, please use one of the alternative methods offered by our organisation.