New Patient Questionnaire

** Please note – you will not be registered until you have completed this section. Please have a copy of your ID and proof of address ready to be uploaded at the end of this form**

As part of the registration process we require all new patients to complete a New Patient Questionnaire. This is to ensure we have your most up to date information to allow us to provide certain medical services after acceptance of registration.

New Patient Questionnaire 2021
Please use format day/month/year e.g. 12/05/1979
Emergency Contact Details
Emergency Contact Details
First Name
Surname
Do you have a history of, or are you currently receiving medication/treatment for: (please tick as appropriate)
Any previous surgical operation(s)?
Vaccination History (If you know it)
Ethnic Origin (Please Tick as appropriate)

Fast Alcohol Screening Test (FAST)

1). 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?
2). How often during the last year have you been unable to remember what happened the night before because you had been drinking?
3). How often during the last year have you failed to do what was normally expected from you because of your drinking?
4). In the last year has a relative, friend, doctor or other health worker been concerned about your drinking or suggested that you cut down?
Maximum upload size: 516MB

Privacy Policy

This form collects your name, date of birth, email, other personal information and medical details. This is to confirm you are registered with the practice, to allow the practice team to contact you and also to update your medical records held by the practice and our partners in the NHS. Please read our Privacy Policy to discover how we protect and manage your submitted data.