New Patient Registration Form | Layton Medical Centre

NHS Number: (If known)

Surname: *

First Name: *

Middle Name(s)

Previous Surname:

Date of birth *

Sex: *

Male

Female

Ethnicity: *

First Spoken Language: *

Town/City and Country of Birth: *

Address: *

Post Code: *

Telephone number:

Mobile number:

Email Addres:

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

Your previous UK address: *

Post Code *

Previous GP Surgery address:

If you are from abroad: (Supply your first UK Address)

If you are from the Armed Forces: Address for enlisting

Service or Personnel number:

Enlisted date:

Discharge date:

Occupation: *

Unemployed:

Yes

If registering a child under 5:

I wish the child above to be registered with the doctor named overleaf for Child Health Surveillance.

Do you wish to receive appointment reminders via text?

Yes

Do you want to register for online access?

Yes

Are we OK to email you if necessary?

Yes

Are you currently pregnant? *

Yes

Carer Status: *

Please supply Carer details if necessary:

Patient next of kin: *

Please supply the following details, Name, address, contact number and relation.

Smoking Status: *

Are you a smoker and thinking of giving up? For advice and help please contact the NHS stop smoking service FREE on: 03001231044

If you are a current smoker, please let us know how many you smoke a day?

Exercise: *

Weight: (in KG) *

Height: (in cm) *

Alcohol Questionnaire

Please select

Visual disability:

Hearing diability:

Other disability

Wheelchair dependant

Speech problem

Other

Do you have any allergies to any medication?

Yes

If you ticked ‘YES’ for the last question, please enter the medications you have allergies to:

Please list medications you are currently taking

Please also supply a copy of any current medication.

Practice Participant Group

Our PPG is is run by volunteer patients and our practice manager to help strengthen the relationship between the practice and you, our patient. If you are interested in joining our PPG, please select ‘yes’. We will contact you with information of our next PPG meeting.

Do you wish to join the PPG?

Yes

Patient Signature: *

Date:

Section

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Checkboxes

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Checkboxes

Option 1

Option 2

If you are human, leave this field blank.