Registered GP :___________________________________
QUEENS AVENUE SURGERY
CONFIDENTIAL MEDICAL REGISTRATION FORM
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Surname
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First Names (in full)
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Previous Surnames
(ie Maiden Name)
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Title: ☐ Mr ☐ Mrs ☐ Miss ☐ Ms ☐ Dr
Date of Birth (day/month/year)
☐ Male
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Town & country of Birth
(If London, please include
Borough)
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Address
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☐ Female
NHS Number Click here to enter text.
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Post code: Click here to enter text.
Telephone number: (Home) Click here to enter text.
(Work) Click here to enter text.
Mobile number:
Email address:
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Occupation/Student:
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If retired, please state previous occupation: Click here to enter text.
Nominate your preferred chemist
to enable us to send your prescriptions electronically:
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Ethnicity
Please indicate your ethnic origin:
☐British or mixed British
☐Irish
☐African
☐Caribbean
☐Bangladeshi
☐Chinese ☐Other (please state):
☐Indian
☐Pakistani
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☐Decline to state
What is your first language? Click here to enter text.
Do you require an Interpreter
Yes ☐
No ☐
Masters/Registration Form Adult/Updated Nov15
Please help us trace your previous medical records by providing the following information:
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Post code: Click here to enter text.
Your previous address in UK
Name of previous Doctor
while at that address
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Post code: Click here to enter text.
Address of previous Doctor
If you are from abroad:
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Post code: Click here to enter text.
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Date you first Click here to enter a date.
came to UK
Your first UK address where
Registered with a GP
If previously resident in UK
date of leaving
If you are returning from the Armed Forces:
Address before enlisting
Enlistment date
Leaving date
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Post code: Click here to enter text.
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Service/
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Personnel number
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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.
☐Any of my organs and tissue or
☐Kidneys
☐Heart
☐Liver
☐Corneas
☐Lungs
☐ Pancreas
☐ Any part of my body
Signature to confirm agreement to organ/tissue donation _________________________
For more information please ask at reception for an information leaflet or visit the website
www.uktransplant.org.uk or call 0300 123 23 23
Masters/Registration Form Adult/Updated Nov15
Please tell us about yourself:
Are you a carer?
☐ Yes
☐ No
Do you have a carer?
☐ Yes
If yes, please tell us the name & address of your
Carer and ask reception for a Carer’s Form.
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Post code: Click here to enter text.
Are you happy for us to contact your carer
about you?
☐ Yes
☐ No
☐ No
Personal Medical History
Have you ever suffered from any important medical illness, operation or admission to hospital? If so
please enter details below:
Condition
Year diagnosed
Ongoing
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☐Yes
☐No
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☐Yes
☐No
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☐Yes
☐No
Family History
Have any close relatives (father, mother, sister, brother only) ever suffered from any of the following:
(please indicate who in the boxes)
Heart attack
Stroke
Diabetes
High blood
pressure
Asthma
Glaucoma
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Cancer
(Please
specify type)
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Allergies
Please list any allergies you have to any drugs/medication:
Name of medication
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What was the problem or upset?
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Masters/Registration Form Adult/Updated Nov15
List of current medication
If you have a copy of your repeat medications, please pass to Reception to copy
Name of medication
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Dosage
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Lifestyle smoking
Do you smoke:
☐ Yes
☐ No
How many cigarettes/
cigars do you smoke
daily?
☐ <1/day
☐ 1-9/day
If you smoke a pipe
how many ounces a
week?
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Are you an ex-smoker?☐ Yes
☐ No
If yes, do you
smoke: ☐ Cigarette ☐ Cigars ☐ Pipe
☐ 10-19/day
☐ 20-39/day
Would you like help
to quit smoking?
☐ Yes
☐ 40+/day
☐ No
When did you give up? Click here to enter a date.
Lifestyle alcohol
Do you drink alcohol:
☐ Yes
☐ No
Units per week: Click here to enter text.
If yes, please answer the questions on the attached alcohol questionnaire.
Communication
vejcommunicating with us eg if you use British Sign Language or you require
If you need any help
information in large print or easy read, please let us know.
Next of kin
Name:
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here to enter text.
Tel. contact number: Click here to enter text.
Relationship: Click here to enter text.
Masters/Registration Form Adult/Updated Nov15
Data sharing consent choices
vejof clinical care, we upload certain medical information so that it is available to other
To maintain continuity
healthcare organisations (eg Emergency Departments). Please read the accompanying leaflet which
details what part of your record is extracted and how it is used to help other NHS organisations.
If you wish to OPT OUT please complete the form found with this leaflet.
Email and Text Consent
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Where you have provided
information on how to contact you, can you confirm you are happy for Queens
Avenue Surgery to contact you by the following:
☐ Yes
By email
☐ No
This will be to send you letters, newsletters etc.
I understand that my emails could be read and intercepted by a third party as emails are not secure.
☐ Yes
By text
☐ No
This will be to send you reminders of
appointments and the result of tests.
Text messages are generated using a secure facility however I understand that they are transmitted over
a public network onto a personal telephone and as such may not be secure. The practice will not transmit
any information which would enable an individual patient to be identified.
Patient Access Registration
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We offer an online service which will enable you to order prescriptions, book appointments and have
access to aspects of your medical record. We require photo ID (passport, driving licence) to enable
access. Please ask a receptionist for details.
Signature
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I confirm that the information I have provided is true to the best of my knowledge.
Date: Click here to enter a date.
Signed:
Signature of patient
☐
Signature on behalf of patient
☐
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For Practice use only:
Email Consent – 9NdS
Email Opt-out - 9Ndy
SCR Data upload – 9Ndo
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

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Text Consent – 9NdP
Text Opt-out – 9NdQ
☐
Dissent from secondary use of GP patient identifiable data – 9NuO ☐
Dissent from disclosure of personal confidential data by HSCIC – 9Nu4 ☐
Masters/Registration Form Adult/Updated Nov15