Newcastle Medical Centre - New Registration Pack

  • Newcastle Medical Centre

    Family doctor services registration

  • Patient's Details

  • Title*
  • Date of birth*
     / /
  • Gender*

  • Please help us trace your previous medical records by providing the following information.

  • If previously resident in UK, date of leaving
     / /
  • Date you first came
     / /

  • Were you ever registered with an Armed Forces GP

  • Please indicate if you have served in the UK Armed forces and/or been registered with a Ministry of Defence GP in the UK or overseas
  • Enlistment date:
     / /
  • Discharge date:
     / /

  • Footnote: These questions are optional and your answers will not affect your entitlement to register or receive services from the NHS but may improve access to some NHS priority and service charities services.

  • If you need your doctor to dispense medicines and appliances
  • Date of signature
     / /
  • NHS Organ Donor registration - I want to register my details on the NHS Organ Donor Register as someone whose organs/tissue may be used for transplantation after my death. Please tick the boxes that apply.
  • Date
     / /

  • Please tell your family you want to be an organ donor. If you do not want to be an organ donor, please visit www.organdonation.nhs.ul or call 0300 123 23 23 to register your decision.

  • Date
     / /

  • All blood types are needed, especially O negative and B negative. Visit www.blood.co.uk or call 0300 123 23 23.

  • Health Questionairre

  • Part 1: Personal Details

  • Date of Birth:*
     / /
  • Gender:*

  • NOTE: For students, current address is your term-time address.

  • NOTE: For students, previous address is your home address (outside of university).

  • Contact Details

  •  -
  •  -
  • Are you happy to receive SMS (text) messages?*

  • Emergency Contact Details

  • Format: Telephone Number.

  • Details of Previous Doctor

  • Ethnic Origin*
  • Date you first came to live in the UK
     / /
  • Do you require an interpreter?

  • Student Information (if applicable)

  • Part 2: Personal Health Questionnaire

  • 1. Medical Conditions

  • Do you have any of the following long-term medical conditions? Please tick all that apply.

  • 2. Past Medical History

  • 3. Medication

  • 4. Disabilities

  • 5. Allergies

  • 6. Carer Status

  • Cervical Screening

  • Cervical screening is available to women and people with a cervix aged 25 to 64 years.

  • Have you had a cervical screening before
  • Date of last cervical screening
     / /
  • Result:

  • HPV Vaccination

  • Have you had the HPV vaccine?
  • 1st Dose
     / /
  • 2nd Dose
     / /
  • 3rd Dose
     / /

  • Part 3: Lifestyle Questions

  • Smoking Status

  • Do you smoke?
  • If no, have you ever smoked?
  • If applicable, when did you quit?
     - -

  • Alcohol Consumption

    • 1 pint of beer/lager/cider (ABV 3.6%) = 2 units
    • 1 small measure (25ml) of spirits = 1 unit
    • A small glass (125ml) of wine = 1.5 units
  • Which best describes your normal exercise pattern (please circle)?

  • Part 4: Family History

  • Does anyone in your family have any of the following medical conditions?

  • Part 5: Summary Care Record

  • Summary Care Records imporve the safety and quality of patient care. Because the Summary Care Record is an electronic record it will give healthcare staff faster, easier access to essential information about you. This helps provide you with safe treatment when you need care in an emergency or when the GP practice is closed. Essential information is medication, adverse reactions and allergies only.

  • Do you want a Summary Care Record?*

  • If you have answered no, please contact our reception for an opt-out form.

  • Understanding of Practice Registration Policy

  • 1. All non NHS services will incur a charge depending upon the service requested. Please confirm current fees with the receptionist.

    2. All photocopies requested by patients will be charged. Please confirm current fees with the receptionist.

    3. Housing letters. It is not our policy to give housing letters to patients.

    4. Bank letters. It is not our policy to give Bank letters to patients.

    5. If you change address, landline telephone number, mobile telephone number or e-mail address, please tell us straight away as you may have moved out of the Practice area. If you move out of the area you may need to change to another G.P.

    6. Forty-eight hours notice is required for repeat prescriptions.

    7. Only one appointment per patient and only one item per appointment. If other members of the family need to see the Doctor, please make another appointment.

    8. Always telephone the Practice to let us know if you cannot attend for an appointment. Failure to do so may stop someone else, who needs to be seen urgently, being seen. Please note if you are more than ten minutes late this will be classed as a “did not attend” (DNA) and the clinician will not be able to see you. If you fail to attend three appointments within 12 months you may be removed from the practice register.


    9. I agree to inform the practice should I seek alternative health care from a private provider. This is to ensure my continuity of care.


    I AGREE TO THE ABOVE TERMS AND CONDITIONS OF MY REGISTRATION AT NEWCASTLE MEDICAL CENTRE

  • Date*
     / /
  •  
  • Should be Empty: