Digital First Beacon Practice New Patient Registration

Beacon Practice New Patient Registration
Choose Registration Type

General Registration University Student International Clinician

General Information
Title *
Name *

First Name Surname
Previous Surname/s
Date of Birth *

Day Month Year
Date
NHS Number
Gender *
Town and country of birth *
Current Address *
Postcode *
Home Phone Number

Area Code Phone Number
Mobile Phone Number
Email
example@example.com
Consent to contact

I consent to be contacted via SMS I consent to be contacted via Email
Previous address in the UK
Name and Address of previous GP practice

Patients arriving from abroad
Are you arriving in the UK from abroad?

Yes No
Your first UK address since arriving from abroad
If previously resident in the UK, date of leaving

Day Month Year
Date
Date you first came to live in the UK

Day Month Year
Date

Next of Kin
Next of Kin

First Name Last Name
Relationship to patient
Next of Kin Telephone Number
Next of Kin Mobile Number
Next of Kin Telephone Email
example@example.com

University Patients
University Status

Undergraduate Postgraduate Staff
Course Title
Course Dates

Vaccinations

Please indicate if you have any of the following

	No	Yes	Date (Approx)
Meningitis C (MEN ACWY)
MMR
COVID19
TB

Lifestyle Information
Do you smoke

Yes No
If yes how much per day
Are you an Ex-smoker

Yes No
If yes when did you stop
Current Weight
Current Height

Additional Information
Are you or have you previously served in the armed forces

Yes No
Does someone care for you

Yes No
Are you a carer

Yes No

Pharmacy Nomination

If you request medication from the surgery the prescription is sent electronically to your chosen pharmacy. Please provide details below of the pharmacy to wish to nominate.
Pharmacy Name
Pharmacy Address

Medical History

Please indicate if you have any of the following

	Condition	Year Diagnosed
Diabetes
Heart Disease
Hypertension (Raised Blood Pressure)
Cancer
Asthma
Stroke

Family History

Please indicate if any member of your family have any of the following

	Condition	Family Member
Diabetes
Heart Disease
Hypertension (Raised Blood Pressure)
Cancer
Asthma

Ethnicity

Information on ethnicity is important because of the need to take into account culture, religion and language in providing appropriate individual care, changing legislation, the importance of providing information on ethnicity for shared care including secondary care and the need to demonstrate non-discrimination and equal outcomes.We would appreciate you completing the details below:
Please select from the list below

Confirmation

I confirm that all the information provided is true and correct to the best of my knowledge.
Patients Signature *

Clear
Date of signature

Month Day Year
Date
Hour Minutes AM/PM Option
Should be Empty: