Registration Page

Email *

Confirm Email

Demographics

Title *

Name *

First

Middle

Last

Previous surname/s

Gender *

Date of Birth *

NHS number

If known

Town and Country of Birth *

Please use N/A if you have never had a previous UK address

What is your current address? *

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Please indicate if you are residing in a refuge or a safe house. This information, whilst treated in the strictest confidence, will be relayed to the GP and to the practice safeguarding Lead.

What is your previous address in the UK? *

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Please use N/A if you have never had a previous UK address

Name of previous GP Practice whilst at that address *

Please use N/A if you have never had a previous UK address

Address of previous GP Practice

Please use N/A if you have never had a previous UK address

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.

Contact details

Do you consent to receive emails? *

Mobile Phone

Do you consent to receive SMS texts?

We use text reminders as well as contacting our patients in regards to messages.

Home number

If registering at Lifton Surgery, do you need us to dispense medicines and appliances?

Marital Status

Next of kin name *

Next of kin contact number *

Are you a carer?

Do you have a carer?

Please list any serious illnesses, accidents, operations or hospital admissions. Please state the year, condition and hospital/operation.

Are you a current smoker? *

Have you ever smoker in the past? *

If you are a current smoker, were you aware that we can refer you to stop smoking clinics?

Have you ever experimented with, become addicted to, or become dependent on drugs/prescription medication?

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

How many units do you have on a day when drinking? *

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

Do you have any of the following long-term conditions?

If you have a long-term condition, please provide the date of your last review.

Please use MM/YYYY as format

Ethnicity

You do not need to submit your ethnicity, however, the collection of ethnicity data is crucial in increasing understanding of the inequalities faced by different ethnic groups in order to improve the planning and delivery of services for those who identify as an ethnic minority.

Ethnic Background *

Summary Care Records (SCR)

The summary care record (SCR) is an electronic record of important patient information, created from GP medical records. It can be seen and used by Health Care Professionals involved in the patient's direct care. These include, Ambulance Paramedics, hospital staff including Minor Injury Units and out of hours services. This can only be accessed by authorised personnel with your expressed consent

Consent Options *

Option One - This is a summary of the following • Medication • Allergies • Adverse reactions
Option Two (recommended) - This is a summary of the following • Medication • Allergies • Adverse reactions • Additional medical information. Additional information will be the following • Long term health conditions • Relevant medical history (procedures that you have had and the care you are currently receiving). • Immunisations
Opt-out

Signature *

Welcome to Tavyside Health Centre

Demographics

Contact details

Ethnicity

Summary Care Records (SCR)