New Patient Registration

New Patient Registration - Woodbridge Hill

New Patient Registration - Woodbridge Hill

Patient's Details

Title *
Please use this date format: DD/MM/YYYY.
Sex *
If from abroad:
Any responses we send will go to this email address.
Can we contact you by text?
Can we contact you by email?
Do you require an interpreter?
Do you have a carer?
Are you a carer?

Next of Kin

If returning form the Armed Forces

Current Health

Smoking Status:
Are you interested in advice on how to quit?

Alcohol Consumption

This is one unit of alcohol:

Amount of different types of drink representing one unit of alcohol

And each one of these, is more than one unit:

Amount of different types of drink representing more than one unit of alcohol
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? *
How often during the last year have you found that you were not able to stop drinking once you had started? *
How often during the last year have you failed to do what was normally expected of you because of drinking? *
How often during the last year have you needed a first drink in the morning to get yourself going after a heavy drinking session? *
How often during the last year have you had a feeling of guilt or remorse after drinking? *
How often during the last year have you been unable to remember what happened the night before because of your drinking? *
Have you or someone else been injured because of your drinking? *
Has a relative, friend, doctor or other health care worker been concerned about the drinking or suggested you cut down? *

Adult Females Only

Have you ever had a cervical smear?
Was it done in the UK?
Was the result normal?
Where was it done?
Have you ever had a breast screening?
Was it done in the UK?
Was the result normal?

Immunisation History

Please list all vaccinations for children under 6.
Please include dates and location.

Medical History

Ethnic Category

Please select:
Do you have any special communication needs?

Pharmacy Nomination

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.

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

Summary Care Record

This practice has started the national Summary Care Record programme which enables each patient to have a summary of their key medical information held securely on the NHS central database, kown as the NHS Spine. This summary record could be used in an emergency if you needed treatment when access to the medical record held by your GP was not available; for example if you call the doctor out of hours. You will always be asked to give permission for this record to be viewed and you have the right to decline.

Please indicate whether you would like to have your own Summary Care Record

A Summary Care Record will be created for you from the details held on our GP clinical system and will contain:

  • Any record we have of your current repeat medication, any acute medication (one-offs e.g. antibiotics) and any recently discontinued medication
  • Any record we have of adverse reactions to medication
  • Any record we have of your allergies

A Summary Care Record will be created for you containing the details itemised above in option 1, plus important additional information you and your GP agree would be useful (e.g. diagnoses - asthma, diabetes etc. pacemaker, end of life care etc.) Please discuss this with your GP practice at your next visit.

A note will be made in your records that you do not wish to have a Summary Care Record. Please note that if you attend A&E or if you need emergency treatment when the GP practice is closed, the clinicians treating you may not have access to key information to help them give you the most appropriate treatment.

Further Information

Patient Access

This will allow you to:

  • Directly book/cancel/change appointments
  • Request a repeat medication
  • Change your nominated pharmacy