CHARTFIELD SURGERY

Please do not attend the surgery unless asked to do so.

Face coverings are mandatory inside our building.

NEW PATIENT REGISTRATION

Title *

First Name(s) *

Calling Name

Last Name *

Date of Birth *

NHS Number (contact your previous GP if unsure)

Gender *

Age (years) - cannot be younger than 5

Age (months)

Height (cm)*

Weight (kg)*

Place of Birth*

Ethnicity *

Main Spoken Language *

Translator *

Primary Contact Number/Home Phone *

Secondary Contact Number

E-mail Address *

Address Line 1

Address Line 2 *

Address Line 3 *

Address Line 4 *

Postcode *

Previous GP Surgery *

Previous GP Address *

If you have never had a UK GP before, please enter the date you first moved to the country

Drug Allergies *

Drug Allergy Detail

Other Allergies *

Other Allergy Detail

Operations and other details

Smoking Status *

NOK Name *

NOK Relationship *

NOK Phone *

Do you have a carer? *

Carer Details

Are you a carer? *

Cared for Details

Please fill all necessary fields before submitting.

Summary Care Record (SCR) Consent

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. Having a Summary Care Record can help by providing healthcare staff treating you with vital information from your health record if they cannot access your medical notes. This will help the staff involved in your care make better and safer decisions about how best to treat you.

You have the choice of what information you would like to share and with whom, and authorised healthcare staff can only view your SCR with your permission. The information shared will solely be used for the benefit of your care.

However, if you do not wish to have a Summary Care Record, you are able to opt out. You can do so by downloading the form by clicking the button below, completing it, and returning it to us either in person or by email to chartfield.admin@nhs.net.

Summary Care Record Opt-Out Form