New Patient Registration Adult Form

Last Updated: 26/04/2024

Patient details

Information about you

If you did not wish to disclose this information please say this in the text box below

What is your sexual orientation?

Heterosexual

Homosexual

Bisexual

Asexual

I do not wish to disclose this

Other

What is your religion or belief?

Consent to contact

Please note not being able to send you SMS messages will mean that we won't be able to send you our automatic appointment reminders or to let you know if we've received a test result as this is typically an automatic system.

If you do not want us to have this permission, we can still assist with your medical needs but we need to confirm that you are aware of the impact it may have for your accessibility to the service.

Do you give consent to be contacted by Park Crescent Health Centre using SMS Text messaging? *

Yes No

Do you consent to be contacted by email? *

Yes No

Do you consent to answer phone messages being left on your mobile? *

Yes No

Do you consent to answer phone messages being left on your landline/home telephone? *

Yes No

Contact Preference

How do you prefer we contact you? *

SMS/Text Messaging

Telephone

Letter

Next of Kin

Your next of kin details are requested so we are able to contact a family member or friend if you are needing assistance at the surgery.

Next of kin name

Relationship to you

Next of Kin Address

Next of Kin Contact Information

Third Party Consent

Your third party contact will be someone who can organise appointments on your behalf, collect prescriptions or fit notes and discuss your care with a clinician. Please be advised that your next of kin and third party are listed separately as they will have different permissions on your medical file.

Please note once a patient reaches their 16th birthday, they will need to complete a consent form in order for their third party contact to discuss care with a clinician, on behalf of the patient. This includes immediate family members.

What is the full name of the person you have chosen to be your third party?

What would you like your third party to have access to?

Discuss your care with a clinician

Collect paperwork on your behalf

Is your third party contact a support/social worker/carer?

If yes, what organisation do they work for?

Do you consent to all staff at this organisation to discuss your care?

Yes No

Nominated Pharmacy

Where would you like to collect your prescriptions?

By filling out the below information you are confirming that you consent to send your prescriptions electronically to your nominated pharmacy.

Name of Pharmacy *

Address of Pharmacy *

Record Sharing

This GP practice is able to share your electronic GP record with healthcare professions caring for you elsewhere e.g. in community, hospital or urgent care services. This may help in your care and may save you from needing to remember your medical history and medications. This surgery uses a computer system called SystemOne that allows the sharing of full electronic records across different health services if patient consent is given. There are two ways in which your information can be shared.

Sharing Out - This controls whether your information entered at this surgery can be shared with other NHS services

Sharing In - This controls whether information that has been made shareable at other NHS services can be viewed by the surgery

Do you consent to sharing out? *

Yes No

Do you consent to sharing in? *

Yes No

Access to System On Line and NHS App

This will provide you access to request ongoing medication, to book some clinician appointments and access to prospective Full Record Access

Do you require access to System Online and the NHS app? *

Yes No

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

Your previous address in the UK

Name of previous GP practice while at that address (if you have not been registered with a GP before please enter N/A) *

Address of previous GP practice

If you are from abroad

Please note that if you have not been registered with a GP Practice before and were not born in the UK we will need the date you came to the UK to be able to register you.

Your first address where registered with a GP

If previously resident in UK, date of leaving

Date you first came to live in the UK. (Please note that if you have not been registered with a GP in England before we need this date to be able to register you)

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

Regular

Reservist

Veteran

Family Member (Spouse, Civil Servant, Service Child)

Enlistment date

Discharge date (if applicable)

Address before enlisting

Service or personnel number

Medicines and Appliances

*Not all doctors are authorised to dispense medicines

If you need your doctor to dispense medicines and appliances*

I live more than 1.6km in a straight line from the nearest chemist

I would have serious difficulty in getting them from a chemist

Medical Information

Medications We Don't Prescribe

Please be aware we restrict some of the medications we prescribe at Park Crescent due to their addictive nature and associated negative side effects. This follows current best evidence for prescribing.

There are some medications that we will not prescribe and if you join the practice, already on these medications, then we will organise an appointment with you in order to discuss this and wean you off them.

The drugs in question come under the following categories

1. Benzodiazepines e.g. diazepam - we do not prescribe this medication

2. Sleeping tablets e.g. zopiclone

3. Opiate based medication for non-cancer pain when used for more than 12 weeks e.g. zomorph, zapain

If you are uncertain the medication you are on comes under any of these categories please ask the reception team who will forward a query to the pharmacy team and / or clinician as appropriate.

In order to ensure that your medication needs are assessed appropriately, we offer all new patients a medication review.

Please select your answer from the following options *

Yes

I need to be contacted by the Reception Team to discuss the above

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 units 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 started? *

How often during the last year have you failed to do what was normally expected of you because of your drinking? *

How often during the last year have you needed an alcoholic 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 remorse after drinking? *

How often during the last year have you been unable to remember what happened the night before because you had been drinking? *

Have you or somebody else been injured as a result of your drinking? *

Has a relative, friend or doctor, or health worker been concerned about your drinking or suggested that you cut down? *

Carers

Are you a carer? *

Yes No

If yes who do you care for?

Parent

Partner/spouse

Child

Friend

Other

if answered other please give details

Do you have a carer?

Yes No

If yes please give details

Routine HIV Testing at Park Crescent

HIV (Human Immune-Deficiency Virus) is a virus which attacks the body's immune system, making it difficult to fight infections. The only way to identify the people affected is to encourage everyone to have a HIV test.

We offer routine HIV tests on all our patients as recommended by the Department of Health, either on registration or as part of routine care. This is because:

It is best practice and recommended nationally
Brighton and Hove have the highest levels of HIV in the country, outside of London
Around a quarter of people with HIV do not know that they have it because they have not taken a test
HIV can now be treated very successfully with medication which can keep people healthy and well and prevent further transmission.

Please book an appointment if you would like to take a test, or let the clinician know at any routine blood test appointments.

Please note: This blood test will ONLY cover routine HIV testing. This will NOT INCLUDE any other tests. If you would like to arrange a blood test, not in relation to routine HIV testing, please contact Reception to arrange a GP consultation.

Would you like the Practice to contact you to arrange a blood test for routine HIV testing? Please note: This blood test will only cover routine HIV testing. This will not include any other tests. *

Yes No

Signature

Signature *

Date of completion *

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New Patient Registration Adult Form

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