New Patient Registration Form (GMS1W)

Please note a separate form is required if you are staying locally and reuquesting temporary access to our services.

Family doctor services permanent registration - GMS1W

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. Your details will be held at the surgery for a limited period of time. Sending this form does NOT guarantee or even imply that you will be accepted onto the practice register.

You may also wish to sign up for Online Services, where you can book appointments, amend your details and order you repeat prescriptions with just a few clicks. For more information or to fill out an online registration form please visit Online Services on our website.

Last Updated: 30/01/2024

Patient's Details

Title

Surname *

First name(s) *

Previous Surname/s

Birth Town *

Birth Country *

Date of Birth *

NHS Number (This comprises of 10 numbers)

Sex

Male

Female

House Name/Number *

Address Line 1 *

Address Line 2

Town *

Postcode *

Telephone *

I am a student at:

IF COMPLETING ON BEHALF OF CHILD UNDER THE AGE OF 16

Parent/Guardian's Name

Contact Number

2nd Parent/Guardian's Name

Contact Number

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

Your previous address in UK (if no previous UK address, please enter 'N/A') *

Name of previous GP practice while at that address (If no previous UK address, please enter 'N/A' *

Address of previous GP practice

If you are from abroad

Your first UK address where registered with a GP

If previously resident in UK, date of leaving

Date you first came to live in UK

Were you ever registered with an Armed Forces GP

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.

Have you ever served in HM Armed Forces? *

Yes No

Enlistment Date

Discharge date (if applicable)

Address before enlisting

Service or Personnel Number, BFPO Number

Complete Registration

*Not all doctors are authorised to dispense medicines

If you need your doctor to dispense medicines and appliances*

I live more than 1 mile in a straight line from the nearest chemist

I would have serious difficulty in getting them from a chemist

N/A

NHS Individual Health Record Opt Out *

I want to opt out of the Individual Health Record and prevent emergency care medical staff being able to access my key medical information. I have received enough information to make an informed decision and I acknowledge that opting out could be detrimental to my healthcare. Further information is available by visiting www.wales.nhs.uk/individuahealthrecord or by calling NHS Direct on 0845 46 47

N/A

Do you wish to receive correspondence from us in Welsh?

Yes No

Signature *

Signature on behalf of patient

Date *

SMS/Email Messaging Service

Do you consent to the practice contacting you by SMS text message for appointment reminders, invitations to health checks, vaccination reminders, prescription reminders and others matters relevant to your healthcare? *

Yes No

We have an electronic method of contact available for patients to contact the surgery for non urgent queries. Do you consent for us to correspond with you via email for this purpose? *

Yes No

What is your ethnic group?

Please tick one box that best describes your ethnic group or background from the options below:

New Patient Health Questionnaire

Family history

Is there any of the following in your family (mother, father, brother, sister) before the age of 65?

Heart disease *

Yes No

Which family member?

Stroke

Which family member?

Cancer *

Yes No

Which family member?

Site of cancer

Carers

Do you have need/have anyone who looks after you or your daily needs as a carer? *

Yes No

Name

Address

Contact number

If you would like them to deal with your health affairs, written consent will need to be supplied. Consent forms are available from reception upon request.

Carers

Do you care for anyone else? *

Yes No

Name

Address

Contact Number

TO BE COMPLETED BY THE DOCTOR

Patient's ID has been checked prior to registration

Doctor's Name:

Authorised signature:

Name:

Date: ____ / ____ / ________

Practice stamp:

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New Patient Registration Form (GMS1W)

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