First Name * Middle Name Last Name * Date of Birth * DD 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 / MM 1 2 3 4 5 6 7 8 9 10 11 12 / YYYY 2022 2021 2020 2019 2018 2017 2016 2015 2014 2013 2012 2011 2010 2009 2008 2007 2006 2005 2004 2003 2002 2001 2000 1999 1998 1997 1996 1995 1994 1993 1992 1991 1990 1989 1988 1987 1986 1985 1984 1983 1982 1981 1980 1979 1978 1977 1976 1975 1974 1973 1972 1971 1970 1969 1968 1967 1966 1965 1964 1963 1962 1961 1960 1959 1958 1957 1956 1955 1954 1953 1952 1951 1950 1949 1948 1947 1946 1945 1944 1943 1942 1941 1940 1939 1938 1937 1936 1935 1934 1933 1932 1931 1930 1929 1928 1927 1926 1925 1924 1923 1922 1921 1920 Ethnicity * *Please choose ethnicity* White British White Irish Other White background Black African Black Caribbean Mixed Black & White African Mixed Black & White Caribbean Other Black background Asian Indian Asian Pakistani Asian Bangladeshi Asian Chinese Mixed White & Asian Other Asian background Arab Any Other Ethnic background Prefer to not specify Main Spoken Language * Do you require an Interpreter? * Town and Country of birth * Previous Home Address * Mobile Phone * Home Phone Work Phone Email * Have you been registered with a GP practice in the *UK?* * No Yes Previous GP Surgery * DATE of entry into the UK * HIV Screening *
All new patients are eligible for free a HIV test which can be done in surgery by our Healthcare Assistant via a blood test
Alcohol Consumption per week (Units) Do you have private insurance? * No Yes
We are an NHS GP Practice. You do NOT need private insurance to register with our practice or use our services.
Nominated Pharmacy *
The Fortune Green Medical Practice can send your medication electronically to a nominated pharmacy of your choice to be ready for collection
Nominated Pharmacy Next of Kin / Emergency Contact Next of Kin/Emergency Contact * Next of Kin Contact Number * Relationship to Patient * Summary Care Record - You have the choice of what information you would like to share and with whom. *ONLY* Authorised healthcare staff can view your SCR with your permission. The information shared will solely be used for the benefit of your care. * Express consent for medication, allergies and adverse reactions only. You wish to share information about medication, allergies for adverse reactions only. Express consent for medication, allergies, adverse reactions and additional information. You wish to share information about medication, allergies for adverse reactions and further medical information that includes: your illnesses and health problems, operations and vaccinations you have had in the past, how you would like to be treated (such as where you would prefer to receive care), what support you might need and who should be contacted for more information about you. Express dissent for Summary Care Record (opt out). Select this option, if you DO NOT want any information shared with other healthcare professionals involved in your care. If you chose not to complete this consent form, a core Summary Care Record (SCR) will be created for you, which will contain only medications, allergies and adverse reactions.
Summary Care Records are an electronic record of important patient information, created from GP medical records. If you are registered with a GP practice in England, you will already have a Summary Care Record (SCR), unless you have previously chosen not to have one. It will contain key information about the medicines you are taking, allergies you suffer from and any adverse reactions to medicines you have had in the past. Information about your healthcare may not be routinely shared across different healthcare organisations and systems. You may need to be treated by health and care professionals who do not know your medical history. Essential details about your healthcare can be difficult to remember, particularly when you are unwell or have complex care needs. Having a Summary Care Record can help by providing healthcare staff treating you with vital information from your health record. This will help the staff involved in your care make better and safer decisions about how best to treat you.
By confirming, you are consenting to leave your current NHS GP practice. You are free to change your NHS GP practice at any time.