Adult new patient registration (16 and over)

Patient’s Details

Please specify:

Family Name/Surname: *

Previous Family Names/Surnames:

Given Name(s)/First Name(s) *

NHS Number:

If known.

Gender Assigned at Birth: *

Male

Female

Do you currently identify as your birth gender?

Yes

No

Please describe your gender:

Town and Country of birth: *

Current Manchester Address: *

Postcode: *

How long will you be at this address?

Less than 3 months

More than 3 months

Are you in a stable housing situation?

Yes

No

Examples of Yes: renting in your own name, living with parents/family, shared student house/hall, own home.

Examples of No: staying temporarily with friends/ family, emergency/temporary housing, homeless.

Home Phone Number:

Mobile Phone Number:

Work Phone Number:

Can we contact you by text?

Yes

No

Can we contact you by email?

Yes

No

Care Home Status

Are you a care home resident?

Yes

No

Which type?

Nursing home

Residential home

If you are from abroad

Date you came to live in the UK:

Please use this date format: DD/MM/YYYY.

Why did you come to the UK?

Previous Details

Have you ever been registered with a GP in the UK?

Yes

No

Name and address of previous GP:

Previous address while registered with that GP:

Please include postcode.

Your Next of Kin / Emergency Contact

Full Name: *

Relationship to you: *

Phone Number: *

Next of Kin address:

I give consent to sharing my patient/medical record with my Next of Kin/Emergency contact:

Yes

No

Communication Needs

Do you have any special communication needs?

Yes

No

Please let us know what you need below.

Support (eg: use hearing aid):

Professional (eg: BSL Interpreter)

Contact Method (eg: Telephone)

Format (eg: Easy Read)

About You

Other White please state:

Other Mixed please state:

Other Asian please state:

Other Black please state:

Any other please state:

Do you have any problems speaking English?

I have no problems

I have some problems

I have a lot of problems

Do you have any problems reading English?

I have no problems

I have some problems

I have a lot of problems

Main Spoken Language:

Main Reading Language:

Do you need an interpreter when you visit the doctor?

Yes

No

Please select which best describes your sexual orientation:

Heterosexual/Straight

Gay/Lesbian

Bisexual

Please specify:

Are you a main carer (unpaid) for someone who has poor health or diasbility?

Yes

No

Are you a military veteran or reservist from the British Armed Forces?

Yes

No

Health and Lifestyle

Height:

Weight:

Do you take regular medication?

Yes

No

Please list your regular medication and dosage:

Name of preferred pharmacy:

Address of preferred pharmacy:

Your prescriptions will be sent electronically to this pharmacy. You can change your pharmacy at any time.

Do you have any long-term illness, health problem or disability?

Yes

No

Please list any any long-term illnesses, health problems or disabilities:

Do you have a carer (paid or unpaid) due to poor health or disability?

Yes

No

Smoking Status:

Current Smoker

Ex Smoker

Never Smoked

How many do you smoke per day?

Are you interested in advice on how to quit?

Yes

No

How many did you smoke per day?

When did you stop?

Alcohol Consumption

This is one unit of alcohol:

Amount of different types of drink representing one unit of alcohol

And each one of these, is more than one unit:

Amount of different types of drink representing more than one unit of 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 or more if male, on a single occasion in the last year? *

Current University students only

Are you currently a full time or part-time University student?

Yes

No

Name of University:

Are you an overseas student?

Yes

No

Access to GP Health Records

All patients will automatically be able to view their prospective GP records using the NHS App. The NHS App, website and other online services are all very secure, so no one is able to access your information except you. You’ll need to make sure you protect your login details. Don’t share your password with anyone as they will then have access to your personal information.

More information on access to your GP health records is available by visiting: GP health record – NHS App help and support

If you do not want to see your health record using the NHS App please tick this box:

I do not want to see my health record using the NHS App

If you would like more information about these changes, please speak to your GP or the reception team.

Summary Care Record

Your GP surgery needs permission to share important information from your GP record. This is called a summary care record (SCR). Your SCR can only be shared with health and care staff across England who are providing you with direct care. It gives them access to vital information from your GP record.

Your options are:

a basic summary care record that includes details of your medicines, allergies and adverse reactions only
an enhanced summary care record that includes details of your medicines, allergies, adverse reactions and any significant illnesses and health problems, operations and vaccinations
opting out of a summary care record meaning you do not want any information shared with other healthcare professionals involved in your care

What is your choice for a summary care record?

Basic summary care record

Enhanced summary care record

Opt out of a summary care record

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