Adult registration

Adult registration form

Last Updated: 14/07/2023

Your Contact Details

Title *

Surname *

First name (s) *

Previous Surname

Date of Birth *

Sex *

Male

Female

NHS Number

Birth Town *

Birth Country *

Address including postcode *

Home Number

Mobile Number

Email Address

Please help us trace your previous medical records by providing the following:

Your previous address in the UK *

Name of GP whilst at previous address *

Address of that doctor/Surgery

If you are from abroad

Please note, we are unable to process your registration if you do not put a date of entry into UK

Date you first came to live in the UK

You need attend the surgery with proof of address if this is the first time in the UK to complete your registration

I agree I will attend the surgery with proof of address and understand my registration will not be complete until I do so

If you are returning from the Armed Forces

Address before enlisting

Service/personnel Number

Enlistment date

Information About You

Medical Information

Carers

Do you have a carer?

Yes No

If yes please give details

Are you a carer? *

Yes No

(If yes please give details)

Women

Have you ever had a cervical smear?

Yes No

If 'yes', please state when, where and the result

Smoking

Smoking status *

If you do currently smoke, how many cigarettes or ounces of tobacco do you smoke per week?

If you are an ex-smoker, what date did you stop smoking

Would you like advice on giving up smoking? *

Yes No

Alcohol

How often do you have a drink that contains alcohol? *

How many standard drinks do you have on a typical day when you are drinking? *

How often do you have 6 or more standard drinks on one occasion? *

Family History

Please state any serious illness, in particular cancer, heart disease, stroke, high blood pressure, diabetes or any inherited disease. Please state your relationship to the individual and in the case of cancer, the type of cancer. *

Next of Kin

Please give name of next of kin *

Please provide address and telephone number for your next of kin *

Relationship of next of kin *

For patients aged 65 and over or those with a chronic disease (e.g. asthma or diabetes)

Have you had a flu vaccination? Enter date or 'never': *

Have you had a pneumococcal vaccination? Enter date or 'never' *

Contacting You

Do you agree that you may be contacted from time to time, via email and/or SMS, with practice news, advice about my health and/or appointment reminders. *

Yes No

Summary Care Record

Summary Care Record (SCR) – used nationally across England

The SCR is a national database intended to help patient care, particularly in emergencies. It contains registration details (name, address, date of birth, NHS number etc) and a list of prescribed medication and allergies. It is useful for an Accident & Emergency department to check for allergies or drug interactions, to improve the treatment they can provide for you. It is also possible to ask for a more detailed SCR containing significant diagnoses, referrals, vaccinations, care plans or other details. Your permission will be checked each time, unless there is a special factor such as being unconscious or otherwise unable to consent. For further information see https://digital.nhs.uk/services/summary-care-records-scr

Summary Care Record *

I would like to have a SCR detailing medication, allergies and adverse reactions ONLY

I would like to have a SCR detailing medication, allergies and adverse reactions AND ADDITIONAL INFORMATION (such as diagnoses, care plans and anything else considered important)

I do NOT wish to have any of my medical details recorded in the SCR

Oxfordshire Summary Care

The Oxfordshire Care Summary and the Out – Hours GP records sharing system

Your patient record is held securely and confidentially on an electronic system controlled by your GP Surgery. Your information can be viewed if you need treatment in another NHS healthcare setting, such as an Emergency Department, Out of Hours, GP, Minor Injury Unit or College Nurse (if applicable). The professionals treating you can give you safer care if medical information from your GP Surgery is available to them. In all these cases, your information will be viewed only by authorised healthcare professionals directly involved in your care. You will be asked permission before the information is accessed unless the health professional is unable to ask you and there is an important clinical reason for accessing it.

Please select one option below *

I agree to opt IN

I do NOT agree to opt in

Signature

Signature *

Date *

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Adult registration

Further Information