Online Registration for Park Medical Practice

Please fill in your details and click Submit when complete. * = compulsory

Please only complete this registration form once. If you have previously submitted this
form at any time please do not do so again unless advised to by the practice.
Please do not use this form to update your address or other details.

* Which of our sites would
you like to register with?

* Title:

Mr Mrs Miss Ms

* Surname:

* First name:

Previous surname/s:

* Date of birth:

NHS Number:

Find my NHS number

* Gender:

Male Female

* Town and country of birth:

* To be completed by University Students only living in halls of residence.

Student halls in Derby:

Flat/Lodge:

Room:

* All other patients, please type in your new address below.
Please include block and flat number if applicable!

House number:

House name:

* Road:

* Town:

* Postcode:

* Mobile phone number:

* Email address:

* Confirm email address:

* What is your preferred contact method?

Letter Email SMS

Do you give explicit consent for us to contact you via text message or email?
Text:Yes No Email:Yes No

* Have you ever worked in the Armed Forces (regular or reserve)?
Yes No
* Are you married to/or a dependant of a veteran or a current member of the Armed Forces?
Yes No

Please help us trace your medical records by selecting if you are a UK or International
patient (Part 1) and then filling in the next section (Part 2)

* Part 1. Select if you are from UK or abroad:

UK Patient
International Patient

Part 2: Fill in if you come from the UK
Previous address in UK before going to University
House Number:
House Name:
* Road:
* Town:
* Postcode:
* Approximate date of first living at this address:
* Name of GP Surgery when at that address:
* Address of Doctor or Surgery: Postcode:

Part 2: Fill in if you come from abroad (international patient)

* Date when you arrived in UK (dd/mm/yy):

* Expected date of leaving UK (dd/mm/yy):

Your first UK address where registered with a GP:
(only if you have previously registered with a GP)

If a previous resident in UK, date you left (dd/mm/yy):

Supplementary Questions:

Please select one of the following options: More information...

	I understand that I may need to pay for NHS treatment outside of the GP practice
	I understand that I have a valid exemption for paying for NHS treatment outside of the GP Practice. I can provide documents to support this when requested This includes for example, an EHIC, or payment of the Immigratin Health Charge ("the Surcharge"), when accompanied by a valid visa.
	I do not know my chargeable status

Complete the following section if you come from another EEA country:
Do not complete this section if you have an EHIC issued by the UK.

Do you have a non-UK EHIC or PRC? Yes No

Tick here if you have an S1
(e.g. if you are retiring to the UK or you have been posted here by your employer for work or you live in the UK but work in another EEA member state). Please give your S1 form to the practice staff. More information...

* Signature:

Clear

Health Questionnaire

Are you a CARER for someone? Formal Informal No	If yes, please state Name, Birthdate & Relationship:
	Tick this box if you care for someone with Dementia:

PRESCRIPTIONS

Prescriptions will be sent to your nominated pharmacy electronically, please select one of the following:

Nearest pharmacy to where you live

Other pharmacy

Name and Postcode:

Find your pharmacy name and postcode

SMOKING
* Do you smoke? Yes No Used to smoke Vape (use eCigarettes)


* Date you stopped smoking:

* Amount you smoke per day:

Would you like assistance to quit smoking? Please contact:
www.livewellderby.co.uk/stop-smoking or call 01332 641254
* Tick here to confirm that you have read the above

ALCOHOL
(to be completed by patients aged 13+)

How many alcohol units per week do you drink?
Not sure of your alcohol consumption?

* HEIGHT:

* WEIGHT:

* ETHNIC GROUP:		Other:
Your first language:

* Patient Access Online

I would like to be able to book/cancel/manage appointments, update my contact details and order repeat
prescriptions online:(if you select yes, your user details and unique pin will be emailed to you once your
medical registration has been fully processed by the health authority – this may take a few weeks)
Yes No

* Summary Care Records (SCR)

Summary Care Record (SCR) - this is an electronic record which contains information about the medicines you take,
allergies you suffer from and any bad reactions to medicines you have had. Having this information stored in one place
makes it easier for healthcare staff to treat you in an emergency, or when your GP practice is closed.

I agree to opt in I do NOT agree to opt in

* Sharing Additional Information within the Summary Care Record (SCR)

It is practice policy to share information that is recorded on your clinical record with other clinical staff
that you are under the care of to ensure the best care is provided to you. For further information
please ask for an information leaflet or visit this site.
Additional information includes reason for medication, significant medical history, significant procedures,
anticipatory care information, communication preferences, end of life care, immunisations.
For further information visit this site.

I agree to opt in I do NOT agree to opt in

Do you need any SPECIAL REQUIREMENTS when attending appointments
(please tick) or please advise of any other:

	Deaf interpreter
	Language interpreter	Other:

Next of Kin

Who you would like us to contact in the event of an emergency?
Name:
Contact Number(s):
Your relationship:

To be completed for patients aged UNDER 16

Who has Parental Responsibility?
Name: Relationship:
Name: Relationship:

Who else lives in the house? Name(s) and relationship(s)

Is the patient under the care of Social Services? Yes No
Name of Social Worker: Department:

Please attach a copy of the child's Birth Certificate:

Organ Donor Registration

The law has changed so that you need to opt out if you do not want to become a donor. It’s
important to talk to your family about your organ donation decision, as they will be asked to
support your decision. If you are undecided or do not want to become an organ donor, please
refer to the NHS Organ Donation website at www.organdonation.nhs.uk or 0300 123 23 23.

Blood Donor Registration

If you are interested in becoming an blood donor, please click this link
to go to the blood donor registration page.

Please read our Privacy Notice.

The information you are submitting will be sent encrypted to the medical practice over the Internet, which still isn't 100% secure.
If you are worried about this you can instead obtain a form from the medical practice that can be filled in and delivered by hand.