New Patients - The Red House Surgery

The Red House Surgery is currently accepting new patients living within our catchment area.

Non-urgent advice: Registrations Notice between 20th November – 5th December

We will not be able to add new registrations between 20th November – 5th December. If you submitted a registration form, this will be action after 5th December. If you would like to register with us and require medical attention during this time, you will need to request a temporary registration. Your temporary registration will expire which means you will be required to register with us formally after 5th December.

Any registration submitted between 20th November – 5th December that does not require medical attention, will be formally registered from 6th December.

* Under 16 Registration Form

Change of Details

Temporary Patient

Are you an Anglia Ruskin Student?

Yes – I am a student

No – I would like to register with Red House Surgery

Title

Mrs

Miss

Other

NHS Number Optional

https://www.nhs.uk/find-nhs-number/what-is-your-name

First Names (As written on official documents)

First

Middle name (As written on official documents)

Middle Optional

Please put your middle name if you have.

Surname (As written on official documents)

Last

Previous Surname

Previous Surname Optional

Date of Birth

DD slash MM slash YYYY

Gender (At birth)

Male

Female

Ethnicity

First Spoken Language

Town and Country of Birth

Cambridge Address (please include a flat/room number)

Street Address Optional Address Line 2 Optional City Optional Postcode Optional

Mobile (UK Only)

Landline (UK Only) Optional

Email Address Optional

Consent to receive SMS notification for clinical services

Yes Optional

No Optional

Consent to receive EMAIL notification for clinical services

Yes Optional

No Optional

Please help us trace your previous medical records by providing the following information. N/A – If this: is the first registration with the GP:

Your previous address in the UK

Street Address Address Line 2 City Postcode

Name of previous GP practice while at that address in the UK

Address of previous doctor in the UK

Street Address Address Line 2 City Postcode

Are you from abroad?

Yes

If you are from abroad:

Date you first came to live in the UK

Day

Month

Year

Please add your date of birth if you were born in the UK

Your first 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

NOT Normally Resident in UK

I am not ordinarily a resident in the UK Optional

European Economic Area (EEA) Country

For a list of EEA countries visit: www.gov.uk/eu-eea

Do you live in another EEA country, or have moved to the UK to study or retire, or live in the UK but work in another EEA member state?

Yes Optional

No Optional

Demographics

Marital Status

Which of the following options best describes you?

Sex and gender identity – Which one of the following best describes how you think of yourself?

Is your gender identity the same as the gender you were given at birth?

Yes

Prefer not to say

Please specify the ethnic group you consider you belong to

What is your main religion?

Communication Needs

Do you speak English?

Yes

Do you read English?

Yes

What is your main spoken language?

Are you a British Sign Language user?

Yes

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 or 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. dyslexia, dyspraxia 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 Optional

No Optional

Carers

Do you have caring responsibilities?

None Optional

Primary carer of a child/children (under 18) Optional

Primary carer of disabled child/children Optional

Primary carer of disabled adult (18 and over) Optional

Primary carer of older person Optional

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

Prefer not to say Optional

Do you have a carer?

Yes Optional

No Optional

Emergency Contact

Full name

First Last

Relationship to you

Contact Number

Are they your next of kin?

Yes Optional

No Optional

Health Questionnaire

Height (centimeters)

Weight (kilograms)

Smoking Status

Current Smoker

Ex Smoker

Never Smoked

How many cigarettes per day?

Ex Smoker / Never Smoked = 0

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 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 (0)

Less than monthly (1)

Monthly (2)

Weekly (3)

Daily or almost daily (4)

How often do you have a drink containing alcohol?

Never (0)

Monthly or less (1)

2-4 times per month (2)

2-3 times per week (3)

4+ times per week (4)

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

Medical History

Major Illnesses

Please include dates.

Past Operations Optional

Please include dates.

Family History Illnesses

Please include dates.

Current Medication

Allergies

Do you have any allergies?

Yes

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

Please include dates.

Immunisation History

If you received any covid vaccination abroad, please state: Date, vaccine, batch number, which arm, dose and from which country

Please list any immunisations/vaccinations you have had Optional

Please include dates.

Important Registration Information

For anyone aged 16 and over, we offer online services for appointment booking and repeat prescription ordering. This is the quickest and easiest way to order your medication. Once registered, you will also be able to view your summary record, detailing current medication, allergies and vaccinations.

You will soon receive an email from the practice with your log in details.

These are confidential: It is your responsibility to ensure they can be received securely by email.

Prescriptions are sent electronically to your nominated pharmacy. We will automatically nominate the pharmacy closest to your post code as part of your registration. If you prefer to use a different chemist please contact the practice to sign up for the Electronic Prescribing Service.

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 – Express consent for medication, allergies and adverse reactions only. OR Optional

YES – Express consent for medication, allergies, adverse reactions AND additional information. Optional

NO – I do not want a summary care record. Optional

Your Medical Information – Sharing Your Data

Under the General Data Protection Regulations (GDPR), we have a responsibility to keep your medical records confidential. We need your consent to share this with other authorised health professionals involved in your care or in planning your care. You can find more information on the website at nhs.uk/your-nhs-data-matters.

Please see the privacy notice on our website for more information on how your data is held and used by the practice.

The NHS wants to make sure you and your family has the best care now and in the future. Your health and adult social care information supports your individual care. It also helps us to research, plan and improve health and care services in England.

There are very strict rules on how this data can and cannot be used, and you have clear data rights. We are committed to keeping patient information safe and will always be clear on how it is used.

You can choose whether or not your confidential patient information is used for research and planning.

If you do not wish your information to be used in this way please opt-out by visiting nhs.uk/your-nhs-data-matters or by calling 0300 303 5678. The practice is unable to record this for you.

NHS Organ Donor registration

For more information on organ donation please visit: www.organdonation.nhs.uk

If you would like to join the NHS Blood Donor Register as someone who may be contacted and would be prepared to donate blood, please visit their website on: www.blood.co.uk or call direct on 03001232323.

Pharmacy Nomination

Pharmacy Nomination Optional

Please Specify Optional

Signature

Clarification

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