Kingsway Surgery
Online Registration

Please fill in your details and click Submit when complete.

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 by the Surgery to do so. If you are unsure of your registration status,
you can contact the practice who will be able to confirm this for you.

Current patients: DO NOT use this form to update your address or other details.

Have you ever registered
with this practice before?

Yes No

* Title:

Mr Mrs Miss Ms

* Surname (Family name):

* First name(s):

Preferred (known as) first name:
(if different from above)

Previous surname(s):

* Date of birth:

* Attach copy of Identification Document:
(ID Card/Passport/Driving licence)

NHS No. (if known):

* Gender:

Male Female

* Town and country of birth:

Please fill in your new ADDRESS in Swansea:

Room/Flat/House:

* Street Address:

* Town:

* Postcode:

* Attach proof of address:
(Document with your name and address)

* Email address:

* Confirm Email address:

* UK Mobile telephone number:

By providing your telephone and email address, you are agreeing to receive email and/or SMS
communications from us. This will include news, information and possibly invitations to attend.

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

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

from UK
from Abroad

Part 2: Fill in if you come from the UK
* Previous Address in UK: (i.e. the address your current GP have for you) * Town: * Postcode:
* Name of Doctor or Surgery when at that address:
* Address of Doctor or Surgery: Postcode:

* Are you currently in the UK?

Yes No

You cannot register with us until you are in the UK

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

* Date when you arrived in UK:

Visa expiry date:
(if appropriate)

Attach copy of Visa:
(if appropriate)

* Have you been registered with
a GP in the UK before?

Yes No

Zero Tolerance Policy
We treat our patients with courtesy and respect and ask for the same in return. We ask that you treat your GP and all other Practice Staff courteously– without violence, abuse or harassment. GPs and their staff have the right to care for others without fear of being attacked or abused. Any behaviour verbal or physical, which causes staff to feel uncomfortable, embarrassed, or threatened, is totally unacceptable. The Zero Tolerance policy includes aggression or threats made in person, over the telephone or in written communication. The Practice considers threatening behaviour to be:
• Attempted or actual aggressive threatening physical actions made towards any member of staff.
• The use of aggressive, threatening or abusive language, (including raising of the voice, swearing and cursing, shouting) which threatens or intimidates staff.
This policy applies throughout the premises. It also applies to any employee or partner away from the practice but only in so far as it relates to the business of the practice. Any instance or threat of physical abuse will be reported to the police. The offender will be removed from the premises by the police. The patient will then be removed from the practice list. Instances of abusive/threatening behaviour will be reported to the Practice Manager, recorded in our incident book and a warning letter will be sent to the patient. The patient may contact the Practice Manager to discuss this Warning Letter if they wish to do so. When the Incident Logbook shows a second recorded offence, the patient will be sent a Final Warning Letter informing them of their breach of the Zero Tolerance Policy and their removal from the Practice list.
By signing this you are agreeing to the Zero Policy, and you will adhere to this.

* Signature:

Clear

Health Questionnaire

* Ethnic origin:

Other:

* Are you a Carer?

Yes No

* Are you being cared for?

Yes No

* Do you have any ALLERGIES to medication?Yes No

* Please state any allergies to medication you have:

* Do you take any MEDICATION at present?Yes No

* Please list any prescribed medicines you use including Name, Dosage and Quantity:

Height:

Weight:

* Do you SMOKE? Yes Never Used to smoke (not now)

* Amount you smoke per day:

For help with stopping smoking, please visit Help Me Quit Wales

or FREEPHONE 0808 250 6885

* Tick here to confirm that you have read the above:

Are you happy to be signed up for ONLINE prescriptions/appointments?

Yes No

Benzodiazepine Policy: Please notes that it is the practice policy that we do not prescribe regular benzodiazepine medication or sleeping tablets (examples include diazepam, nitrazepam, temazepam, zopiclone and zolpidem)
It is our practice policy for all new patients to be reviewed.
All patients, without exception, who are taking the above medication will be started on a reduction program until
the medication is stopped.
This will be carried out in a controlled way following the Local Health Board guidelines.
It is the patient’s responsibility to provide evidence of any current medication from their previous practice.

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.
* = Compulsory.

Kingsway Surgery Online Registration

You cannot register with us until you are in the UK

Kingsway Surgery
Online Registration