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.

* Title:
 
 If you don't know your NHS number it's very important that you fill in part 1 and 2 below
Please contact your previous surgery to get your NHS
number. Failure to do so can slow down your registration.
* Gender:
 
* Select your new University address from the list below if you are staying in University accommodation
or; All other patients, please type in your new address below.
Please include block and flat number if applicable!

Enter your own telephone number. Preferably your mobile number

Enter your e-mail address
Confirm your e-mail address
Do you give explicit consent for us to CONTACT YOU via text message or email?
Text:
                 Email: 
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:
Part 2: Fill in if you come from the UK
Previous address in UK before going to University




*

*

*




* Approximate date of first living at this address: Date you first lived at this address


Part 2: Fill in if you come from abroad (international patient)
Date you think you will leave UK

Date you left UK if you had registered with a GP before
Supplementary Questions:
Please select one of the following options: More information...
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?   

(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:
Please draw your unique signature in the box
   
Health Questionnaire
 
Current personal medical history
Have you currently any of the following?
 
Past personal medical history
Have you ever had?
 
Family medical history
Has your birth Mother/Father/Brother/Sister been diagnosed with any
of the following and were less than 60 years old at diagnosis?
         
 
Any other current and past MEDICAL /
SURGICAL / MENTAL HEALTH ISSUES
 
Please specify name of condition and
year of diagnosis (if known):
 
Are you a CARER for someone?
 
 
IMMUNISATIONS
If known, please complete your vaccination dates for:
   
   
Have you previously been screened for TB?  
 
PRESCRIPTIONS
Prescriptions will be sent to your nominated pharmacy electronically, please select one of the following:
 
 
   
 
SMOKING
* Do you smoke?
    
    
Would you like assistance to quit smoking? Please contact:
www.livewellderby.co.uk/stop-smoking or call 01332 641254
*
 
ALCOHOL
* How often do you have a drink that contains ALCOHOL?
   
NHS Alcohol Unit Calculator
* How many standard alcoholic drinks do you have on a typical day when you are drinking?
* How often do you have 6 or more standard drinks on one occasion?
 
If your total alcohol score above is high it may indicate hazardous or harmful drinking.
Please then complete the more detailed questions below (score in brackets):
 
How often during the last year have you found that you were not able to stop drinking once you had started?
 
How often during the last year have you failed to do what was normally expected from you because of your drinking?
 
How often during the last year have you needed an alcoholic drink in the morning to get yourself going after a heavy drinking session?
 
How often during the last year have you had a feeling of guilt or remorse after drinking?
 
How often during the last year have you been unable to remember what happened the night before because you had been drinking?
 
Have you or somebody else been injured as a result of your drinking?
 
Has a relative or friend, doctor or other health worker been concerned about your drinking or suggested that you cut down?
Your alcohol score is: 0
0 – 7: Lower risk, 8 – 15: Increasing risk, 16 – 19: Higher risk, 20+: Possible dependence
 
 cm  kg
 
   
 
* 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)
  
 
* 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.
    
 
* Enhanced Data Sharing Model
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 www.nhscarerecords.nhs.uk/carerecords.
Do you consent for us to share your medical records with other medical service
you may be using i.e. District Nurse Teams, Podiatry or Dieticians?
  
 
Do you need any SPECIAL REQUIREMENTS when attending appointments
(please tick) or please advise of any other:
   
   
 
Next of Kin
Who you would like us to contact in the event of an emergency?
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, alternatively you can fill out the form below.
 
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.
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