New Patient Registration

Boundary Area

Catchment Area

Please complete this registration form ensuring all required fields are completed. Submitting this form will register you with The Manor Surgery in Beeston, Nottingham.

Before registering with the surgery, please ensure that you are living within the surgery’s catchment area.

Please note that if you are trying to register a new born baby, the forms will need to be collected from the surgery.

If this is your first time registering with an NHS GP Practice, you will need to fill in a GMS1 form. This form can be collected from the surgery.

You can register using this link: https://gp-registration.nhs.uk/C84080

Introduction to The Manor Surgery

New Patient Registration Form (GSM1 + Health Q’s)

If you are new to the area and wish to register with the Practice please complete the form below – each person registering will need to complete a form.

Personal Details

Title

Mrs

Miss

Other

NHS Number Optional

First Names

Surname

Previous Surname Optional

Date of Birth

Day

Month

Year

Gender

Female

Male

Ethnicity

Main Spoken Language

Town and Country of Birth

Address

Street Address Address Line 2 City Postcode

Main Contact Number

Home Contact Number Optional

Enter Email Optional Confirm Email Optional

Nominated Pharmacy

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

Your previous address in the UK

Street Address Optional Address Line 2 Optional City Optional Postcode Optional

Address of previous doctor

Street Address Optional Address Line 2 Optional City Optional ZIP / Postal Code Optional

If you are from abroad

Your first UK address where registered with a GP

Street Address Optional Address Line 2 Optional City Optional Postcode Optional

If previously resident in UK, date of leaving

Day Optional

Month Optional

Year Optional

Date you first came to live in the UK

Day Optional

Month Optional

Year Optional

Disability

Do you have an impairment, health condition or learning difference that has a substantial or long term (over a year) impact on your ability to carry out day to day activities? (Tick all that apply)

No known impairment, health condition or learning difference Optional

A long standing illness/health condition such as cancer, HIV, diabetes, chronic heart disease, asthma, or epilepsy Optional

A mental health impairment, such as depression, schizophrenia or anxiety disorder Optional

A physical impairment or mobility issues, such as difficulty using your arms or using a wheelchair or crutches Optional

A learning difficulty Optional

Neuro-diverse e.g. dyslexic, dyspraxic or AD(H)D Optional

Deaf or hearing impaired Optional

Blind or have a visual impairment uncorrected by glasses Optional

An impairment, health condition or learning difference that is not listed above Optional

Prefer not to say Optional

Do you have any specific information or communication needs? If so, please specify how we can meet these for you (e.g. large print, Braille, easy read communications) Optional

Armed Forces

Have you served in the UK Armed Forces and/or been registered with a Ministry of Defence GP in the UK or overseas?

Yes

Do you have access to secure housing?

Yes

What is your current immigration status?

Asylum Seeker Optional

Failed Asylum Seeker Optional

Carers

Do you have caring responsibilities?

None

Primary carer of a child/children (under 18)

Primary carer of disabled child/children

Primary carer of disabled adult (18 and over)

Primary carer of older person

Secondary carer (another person carries out the main caring role)

Prefer not to say

Do you have a carer?

Yes

Emergency Contact

Full Name

Relationship to you

Contact Number

About You

Height

Weight

Smoking Status

Current Smoker

Ex Smoker

Never Smoked

What do you smoke? Optional

e.g. Cigarettes, Vape, Cigars

How many do you smoke per day? Optional

Are you interested in advice on how to quit?

Yes Optional

No Optional

Alcohol Consumption

This is one unit of alcohol:

Half pint of regular Beer/Lager/Cider
1 small glass of wine
1 single measure of spirits
1 single measure of aperitifs
1 small glass of sherry

Each of these is more than one unit:

Pint of regular Beer/Lager/Cider (2 Units)
Pint of Premium Beer/Lager/Cider (3 Units)
Alcopop or can/bottle of regular Lager (1.5 Units)
Can of Premium Lager/Strong Beer (2 Units)
Can of super strength lager (4 Units)
Glass of wine (2 Units)
Bottle of wine (9 Units)

How often do you have a drink containing alcohol?

Never

Monthly or less

2-4 times per month

2-3 times per week

4+ times per week

How many units of alcohol do you drink on a typical day when you are drinking?

1-2

3-4

5-6

7-9

10+

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?

Never

Less than monthly

Monthly

Weekly

Daily or almost daily

Do you have any significant family history we should be aware of? Optional

Allergies

Do you have any allergies?

Yes

Please specify what you are allergic to, what happens and when you had your first reaction

Immunisation History

Please list any immunisations/vaccinations you have had Optional

Please include dates

Summary Care Record

This record will contain summary information about any medicines you are taking, allergies you suffer from and any bad reactions to medicines you have had to ensure those caring for you have enough information to treat you safely.

Your Summary Care Record will be available to authorised healthcare staff providing you with care anywhere in England, but they will ask your permission before they look at it. This means that if you have an accident or become ill away from home, healthcare staff treating you will have immediate access to important information about your health.

Do you consent to having a Summary Care Record?

Yes

EDSM- Enhanced Data Sharing Model

The EDSM allows your GP to share your record with other healthcare providers. This will help to deliver better and safer care for you.

Sharing Out- Do you consent to the sharing of data recorded by your GP practice with other NHS organisations that may care for you?

Yes

Sharing In- Do you consent to your GP Practice viewing data that is recorded at other NHS organisations and care services that may care for you?

Yes

Signature

Declaration

I certify that the information I have provided is correct and consent to my personal and medical information being used as stated above. Optional

Signature

Your Full Name

Date

Day

Month

Year

Boundary Area

Catchment Area

New Patient Registration

New Patient Registration Form (GSM1 + Health Q’s)

Personal Details

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

If you are from abroad

Disability

Armed Forces

Carers

Emergency Contact

About You

Alcohol Consumption

This is one unit of alcohol:

Each of these is more than one unit:

Allergies

Immunisation History

Summary Care Record

EDSM- Enhanced Data Sharing Model

Signature

Thank you for your feedback.