New Patient Registration Form

Fields marked "REQUIRED" are compulsory. You should only send this form if you are sure that you are eligible to join this practice. Sending this form will NOT automatically register you with the surgery nor does sending this form guarantee or even imply that you will be accepted onto the practice register. Registration can take up to 28 days to complete.

Last Updated: 29/09/2021

About You










Contact Informartion






Residency





Occupation


Service families & military veterans

As a practice, we fully support the Armed Services Covenant. We can only do this if we know our patients connections to the Armed Forces. Please tick the boxes below that apply to you,







Students




Ethnicity

Having information about patients ethnic groups would be helpful for the NHS so that it can plan and provide culturally appropriate and better services to meet patients needs. Please indicate your ethnic origin by ticking below.

Various






Carer Status






Next of kin (For emergency contact)








Martial Status



Contacting You

We will use your contact details to send reminders about appointments, reviews and other services which may be of benefit in your medical care




Record sharing

Guildhall Surgery would like to hold, process and share your personal and medical records, manually and electronically, as outlined below. Please note - We use partner software suppliers and businesses who may have access to specific parts of your data (e.g.to send letters/text reminders). We have approval from Kent and Medway CCG to use these companies and we are confident your data is secure.



Electronic Prescribing Service (EPS)



Donation wishes

If you live England, Wales or Jersey, are not in a group excluded from opt out legislation and you have not registered an organ donation decision, it will be considered that you agree to be an organ donor. This is known as deemed consent. If you do not want to donate your organs than you should register your decision. To opt out, visit: https://www.organdonation.nhs.uk/register-your-decision/do-not-donate/



Resuscitation wishes and Power of Attorney




Smoking Status

Smoking is the UKs single greatest cause of preventable illness. Stopping smoking is not easy but it can be done, and there is now a comprehensive, NHS Smoking Cessation Service offering support and help to smokers wanting to stop, with cessation aids available on NHS prescription.




Blood Pressure


Alcolhol intake



Exercise, Weight & Height

If you would like advice on managing a healthy weight, please contact https://www.nhs.uk/live-well/ or visit our website



General Practice Physical Activity Questionnaire








Disabilities / Accessible information standards

As a practice we want to make sure that we give you the information that is clear to you. For that reason we would like to know if you have any communication needs.






Family history and past medical history

Have any close relatives (parent, sibling or child only) ever suffered from any of the following
























For females only







Third Party Consent

If you would like us to speak to a 3rd party about your medical records we require your consent to allow this to happen. If we do not have consent, we will be unable to discuss information with anyone but you.









Additional Information to Support your Registration


Declaration