South Hermitage Surgery
New Patient
Information Form
Please help us get all the details we need to ensure we give you the best possible care and that you
make the most of all the services we have to offer by filling out this form when you join us.
Administrative
Patient full name: ___________________________________________________________________
Date of Birth: _____ / _____ / _____
Up to date mobile number: ______________________________
Please tick this box only if you DON’T WANT to receive text appointment reminders from us
□
Are you in the Practice Area?
□ Yes - my postcode is within the Practice area (our Receptionist can check this for you)
□ No - my postcode is out of the Practice area – I would like details on how to register as an Out
of Area Patient
Your named GP
If you are aged 75 or over you are entitled to have a named GP to co-ordinate your care. This person
is responsible for overseeing your care, but may not always be the clinician you see. Please indicate
your choice of a named GP from the following boxes:
□ Dr Sue Murphy
□ Dr Laurie Davis
□ Dr Mike Moon
□ Dr Yvette Smith
□ Dr Annica Goddard
□ I don’t mind which GP
(you can change your mind anytime by telephoning the surgery)
Online
My current email address: _______________________________________________________
□
Yes please, I’d like to register for online appointment booking, prescription ordering and access
to my medical record. I have provided proof of my identity.
By ticking this box and providing proof of your identity we will generate a PIN code and instructions
which you will be able use to register securely with Patient Access, either on your PC or via the App.
How would you like to receive your PIN?
By email?
□
□
By post?
□
Collect from the surgery?
□
Yes please, I’d like to receive quarterly newsletters and occasional online surveys about the
care and services at the surgery via email.
Data Sharing
All patients have a Summary Care Record automatically. TO OPT OUT of Summary Care Record :
Please sign here if only you DO NOT WANT a Summary Care Record.
Signature: __________________________________________________________________
□
Please tick this box to confirm that you understand that if you DO NOT have a Summary Care
Record other NHS healthcare staff caring for you (A&E, Shropdoc etc) may not be aware of your
current medications, allergies you suffer from and any bad reactions to medicines you have had in
order to treat you safely in an emergency.
If you are signing on behalf of another person or a child, their GP will consider this request. Please
complete your details below:
Name: _____________________________________________________________________
Relationship to patient: _______________________________________________________
Repeat Medication
Let us know which local pharmacy you would like to collect your regular repeat prescription
medication from.
Your repeat prescriptions will be collected on your behalf from the surgery by the pharmacy staff,
but it is still your responsibility to let the pharmacy know every time you submit a request as they
may not collect from us every day.
Name of Pharmacy: _________________________________________________________________
Are you a Carer?
□
Yes, I am a carer and I would like my name to go onto my GPs Carers register.
I care for …………………………………………………………………………………………………………………. (name/s)
The person/people I care for is/are my:
□ Parent/Parent-in-law
□ Husband/Wife/Partner
□ Child
□ Other family member
□ Neighbour/friend
Is the person you care for registered
at South Hermitage Surgery?
□ Yes □ No
Your Lifestyle
Are you a current smoker?
□ Yes
□ No
If yes, how much do you smoke? _________ Cigarettes per day or __________ Grams per week
Are you interested in attending a Help 2 Quit clinic?
Have you ever smoked?
□ Yes
□ Yes
□ No
□ No
The approximate year that you quit? ____________
Please answer some questions about your alcohol consumption by circling the appropriate answers:
How often do you have a
drink that contains alcohol?
How many units do you have
on a typical day when you are
drinking?
In the last 6 months, how
often have you had more than
6 units on any one occasion if
female, or more that 8 units if
male?
Never
Monthly
or less
2-4 times
a month
2-3 times
a week
4 + times
a week
1–2
3–4
5–6
7–9
10 +
Never
Less than
monthly
Monthly
Weekly
Daily or
almost
daily
Are you interested in attending a Help 2 Slim clinic with our Healthcare Assistant?
□ Yes
□ No
Your Lifestyle contd…
Please use our automated machines to let us know your current:
Height:
Weight:
BMI (Body Mass Index):
Blood Pressure:
Health Check
We would love all our new patients to have a Health Check when they join us.
Please tick the relevant boxes to that we can book the right appointment for you.
I am aged between 40 & 74
□ Yes
□ No
I have one of the following medical conditions – hypertension, heart disease, stroke, kidney disease,
□ Yes
diabetes)
□ No
You’ve finished - Thankyou!
Please hand your completed form to our receptionist.
Staff use only
Patient identity verified for Online Access:
□ Yes
Initials: ______________
□ No
V 1.4 amended 18/02/15