New Patient Registration | Newton Drive Health Centre

DUE TO AN INCREASE IN THE NUMBER OF PEOPLE WANTING TO REGISTER WITH OUR SURGERY IT IS TAKING LONGER THAN USUAL FOR US TO REGISTER EVERYONE.

Your registration will be processed within 3 weeks of you submitting it and you will receive a text message once your registration with us is complete.

Please remember

You will still be registered with your old surgery until we confirm your registration with us is complete. You can continue to access medication and services with them until this time.
If you are registering with us and have not been registered with a GP in the UK before you cannot access our services until you are fully registered, if you have a medical problem in the time between completing your form and your registration being completed, please access care at the Walk In Centre on Whitegate Drive.
If you are registering a new born baby and you are the birth mother and already registered here, you can access care with us for your baby if needed whilst you wait for the registration to be completed.
Please do not contact reception to check the status of your registration, they will not be able to help you. You will receive a text message once your registration is complete, if there are any problems with your registration we will contact you to discuss it.

New Patient Registration

Welcome to Newton Drive Health Centre.

Before you start filling in this form please ensure that you have read the following and have everything you need:

• One form must be completed for each person you wish to register.

• I.D. for everyone aged over the age of 16 – such as a Driving Licence, Passport, or 2 items showing your current address (dated within 3 months).

• List of your current medication.

To ensure we can best care for your needs, this form must be completed in full. Failure to provide all of the information or documents requested may result in a delay processing your registration.

The information provided on this application will, in no way, discriminate against you being accepted on to our practice list.

* = Required field

If you are registering on behalf of another person, please fill out this form with their details.

Have you ever been registered at Newton Drive Health Centre? *

Yes

Reason for leaving?

Approximate leaving date?

If Yes, please provide approximate date and reason for leaving the Practice. This will allow us to link to your past medical history to the new registration.

Prescribing of Controlled Drugs

The Practice policy is not to prescribe the following drugs unless you provide written evidence from the previous G.P. Surgery as these drugs can be dangerous in long-term use.

Benzodiazepine and /or Sleeping tablets including:

Morphine Derivatives including:

We do not prescribe Methadone, Diamorphine, Buprenorphine (Subutex) or Melatonin at all.

Even with previous GP evidence you will be required to commit to a reduction strategy if your dose is above practice policy levels.
THIS IS NONE NEGOTIABLE.

By checking this box and progressing past this section of the form, you are agreeing to adhere to the policies set out by the Practice regarding the ongoing use of Controlled Drugs: *

I Agree

Patient Details

First Name *

Surname *

Previous surname/s

Date of birth *

Town & Country of birth. *

Gender *

Male

Female

Is this the same gender as birth? *

Yes

(If no, please give details)

NHS number (this is a 10 digit number, if you do not know yours you do not need to enter anything)

Your NHS number is a 10 digit number. Please add that here without any spaces.

If you do not know your NHS Number, please click here: Find My NHS Number

Home address *

Postcode *

Telephone Number *

Mobile Number *

Email address: *

What is your occupation? *

What is your first language? *

Do you require an Interpreter? *

What is your Ethnic Group?
Please tick one box that best describes your ethnic group or background from the options below:

White:

Mixed:

White and Black Caribbean

White and Black African

White and Asian

Any other Mixed background (please write in)Any other Mixed background (please write in)

Asian or Asian British:

Indian

Pakistani

Bangladeshi

Any other Asian background (please write in)Any other Asian background (please write in)

Black or Black British:

Other ethnic group:

Chinese

Filipino

Any other ethnic group (please write in)Any other ethnic group (please write in)

Not stated

Not stated should be used where the PERSON has been given the opportunity to state their ETHNIC CATEGORY but chose not to.

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

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

Yes

Your previous address in the UK (even if the same as current address): *

Name and Address of previous GP practice while at that address: *

Date you first came to live in the UK:

if you have previously been registered with a GP in the UK, then you moved away outside the UK but have now returned, please give details of the dates you left and then returned:

Armed Forces

Were you ever registered with an Armed Forces GP *

Yes

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 Partner, Service Child)

Address before enlisting:

Postcode:

Service or Personnel Number:

Enlistment Date:

Discharge Date (If applicable):

Footnote: These questions are optional and your answers will not affect your entitlement to register or receive services from the NHS but may improve access to some NHS priority and service charities services.

Carers
A carer is someone who looks after a relative, child or friend who, because of old age, physical or learning disability or any other illness - including a mental illness, cannot manage without support.

Do you have a Carer? *

Yes

Please give details:

Are you a Carer? *

Yes

Please give details:

Next of Kin

By filling this section in you are consenting to this information being used or shared in the event of an emergency.
Please note: the person you nominate as your Next of Kin must be currently living in the UK with a UK based contact number.

Name: *

Relationship to you: *

Address: *

Telephone Number: *

Do you hold a living will?
A living Will is documentation regarding your personal wishes in respect of medical intervention at the time of serious illness.

Yes

Do you have a Lasting Power of Attorney in place?
A lasting power of attorney is a legal document that lets you appoint one or more people to help you make decisions or to make decisions on your behalf.

Yes

Do you have DNACPR in place??
This means 'Do not attempt cardiopulmonary resuscitation'.
It means that if a person has a cardiac arrest or dies suddenly, there will be guidance on what action should or shouldn't be taken by a healthcare professional, including not performing CPR.

Yes

Lifestyle

Are you a smoker? *

Yes

If no, have you ever smoked? *

Yes

If yes, please complete below:

Cigarette smoker

How many Cigarettes do you smoke per day?

Rolls own cigarettes

How many grams do you smoke per week?

Pipe smoker

How many grams do you smoke per week?

Cigar Smoker

How many cigars do you smoke per day?

Electronic cigarette smoker

Nicotine strength in mg?

For help and advice in stopping smoking please ask for a referral to the smoking cessation service.

Do you have an up-to-date Blood Pressure reading?

Yes

Value

Do you know your current weight?

Yes

Value in kgs

Do you know your current height?

Yes

Value in cm

Looking at the chart below, how many units of alcohol do you drink each week? *

Allergies

Are you allergic to anything? *

Yes

If Yes, please give details:

Women's Health (If Applicable - Please only answer these questions if you are biologically female)

Are you pregnant?

Yes

If Yes, how many weeks?

Have you ever had a cervical smear?

Yes

N/A

If Yes, please state where and when:

Have you ever had a Hysterectomy (removal of womb)?

Yes

Have you had a Bilateral Oopherectomy (removal of ovaries)?

Yes

Have you ever had a Mastectomy (removal of breasts)?

Yes

If Yes, was it a single or double Mastectomy?

Single

Double

Medication & Health Checks

If you are on regular medication or suffer from a chronic disease you will be made an appointment for a new patient health check.
We will inform you of this by telephone or text message.

Please inform us in the box below of any dates and times that you are unavailable to attend an appointment:

It is practice policy not to issue any medication to patients prior to approval of their registration.

It is your responsibility to ensure that you have at least a 3-week supply of any regular medication prior to submitting your registration forms to us. You must also provide us with a repeat medication slip stating the medication you are on and the dose ( these can be obtained from your pharmacy).

You cannot continue with your registration without uploading your medication list here:

You can take a picture of your medication list on your mobile phone and upload it here as long as all the words are visible and the image is not blurry.

Medication List Upload Area:

Maximum file size: 8MB

Electronic Prescription Service

Newton Drive Health centre is able to send all prescriptions electronically through the Electronic Prescription Service (EPS).
If you have a preferred Pharmacy where you would like us to send your prescription, please list it below.
If you do not nominate a Pharmacy we will nominate one for you that is closest to your home address.

My nominated Pharmacy is:

Consent

The NHS app & Online Access can be used for re-ordering repeat medication, booking routine GP appointments and updating your personal information.
By signing this registration form, giving us your email address and providing us with proof of your I.D. we will automatically accept you for this service and send out a registration email. Registration can take up to 8 weeks due to your records needing to be checked.

Are you filling this form out for yourself or on behalf of someone else? *

Myself

Someone else

Your relationship to the person who wishes to register:

Full Name:

Signature *

Clear

Date:

ID Upload Area

Please upload a photograph of your Identification below.
This can be a Driving Licence, Passport, a utility bill dated within the last 3 months or a council tax bill that matches your current address.

All ID that is submitted is stored and destroyed in line with GDPR regulations. We will not keep a copy of your Identification for longer than we need to or for purposes outside of the registration process

Maximum file size: 8MB

If you are unable to provide any of the identification listed please tell us why here. Not being able to provide this documentation will not prevent you from registering with the Practice, we may, however, need to make extra checks to verify your identity.

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