New Patient Questionnaire

We do not accept onto our practice list patients who are already registered with a doctor locally.  We also prefer that whole families are registered under the care of one medical practice; all members of the family need to be either registered here or elsewhere.

The doctors reserve the right to prescribe all medicines according to the best medical evidence currently available; for example we do not prescribe antibiotics and cough medicines for flu, common colds, most sore throats and coughs because there is no cure for these.

We will regularly review all repeat medications and sick notes rather than simply issuing them routinely, even if this has been the policy of a previous practice.

Drug addiction – WE DO NOT prescribe addictive medications such as Methadone.

New Patient Questionnaire

New Patient Questionnaire Form

1. Background Details

Contact Details

Address
Address
Postcode
City
Country
Previous Address
Previous Address
Postcode
City
Country

I consent to be contacted* by SMS on this number

I consent to be contacted* by email

Next of Kin

* It is your responsibility to keep us updated with any changes to your telephone number, email & postal address. We may contact you with appointment details, test results, health campaigns or Patient Participation Group details. If you do not consent to being contacted by SMS or Email, please tick here:

Other Details

Previous GP

Address
Address
Postcode
City
Country
Ethnicity
Overseas Visitor
Armed Forces

Communication Needs

Language

Do you need an interpreter?

Communication

Do you have any communication needs?
Please specify below

Learning disability

Do you have a Learning Disability?

(If yes please request a Learning Disability Screening Tool form)

Carer Details

ARE YOU a carer?
Do you HAVE a carer?

Your carer’s details

* Only add carer’s details if they give their consent to have these details stored on your medical record