Immunisation History Title First Name
Sex Ethnicity Select… White – British White – Irish White – Turkish White – Greek White – Kurdish White – Other Asian – Indian British Indian Asian – Pakistani British Pakistani Asian Bangladeshi Asian – Other Black – Caribbean Black – African Black – Other Mixed – Caribbean Mixed – African Mixed – White & Asian Mixed _ Other Ethnic – Chinese Ethnic – Filipino Ethnic – Vietnamese Ethnic – Other I do not wish to disclose Address (UK Only)
Consent to receive SMS notification for clinical services Consent to receive EMAIL notification for clinical services 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
Address of previous doctor
Are you from Abroad? If you are from abroad: Your first address where registered with a GP
If previously resident in UK, date of leaving Date you first came to live in the UK Resident in the UK European Economic Area (EEA) Country 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? Demographics Marital Status Select… Single, never married Married Civil Partnership Divorced Widowed Separated Are you British Sign Language user? 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
A long standing illness or health condition such as cancer, HIV, diabetes, chronic heart disease, asthma, or epilepsy
A mental health impairment, such as depression, schizophrenia or anxiety disorder
A physical impairment or mobility issues, such as difficulty using your arms or using a wheelchair or crutches
A learning difficulty
Neuro-diverse e.g. dyslexia, dyspraxia or AD(H)D
Deaf or hearing impaired
Blind or have a visual impairment uncorrected by glasses
An impairment, health condition or learning difference that is not listed above
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 If you are filling this form on behalf of a child the Surgery will need to check that you have the authority to do so. Please complete your details below. Full name
Full name of parents / guardian / person with parental responsibility Name
Optional Are there any other children in the family? Please tell us about other children in the family Optional Allergies Do you have any allergies? Please specify what you are allergic to, what happens and when you had your first reaction Optional Please include dates Immunisation Histor Please list any immunisations/vaccinations you have had Optional Please include dates.If you received any covid vaccination abroad, please state: Date, vaccine, batch number, which arm, dose and from which country 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? 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 www.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:
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:
blood.co.uk or call direct on 03001232323. What happens to my information? Pharmacy Nomination Optional Select… Boots Chesterton Road Boots Newmarket road Boots Petty Cury Boots Grafton Centre Lloyds Arbury Court Milton Road Pharmacy Rowlands Histon road Tesco (Milton) Lloyds (Inside Sainsburys) Asda Other, please state name and post code Signature confirm