Online Registration – Adult « Hendon Way Surgery

Date of Birth*

Please help us trace your previous medical records by providing the following information

Name of Previous GP*

Address of Previous GP*

Your Previous Address*

This is usually the address when you were last registered with a GP. Please include full address with POSTCODE

Your first UK address*

Please include full address including POSTCODE

Date you first came to UK*

Address and Postcode before enlisting*

Service or Personnel Number*

Electronic Signature (Type your full name here)*

By completing the section above, I hereby sign this form electronically

NHS Organ Donor Registration

NHS Blood Donor Registration

My preferred address for donation is:

Main Language (if not English)*

Other - Please specify

Relationship to you*

Female patients only

If aged 25-64 years old, when did you last have a cervical smear test?

What was the result?

If you know the reading, enter it here

How many hours of exercise do you take in an average week?

Hidden

Total for questions 1-3*

Hidden

Total Audit Score*

Contact Authorisation

I understand that my GP Practice will take all reasonable steps to keep my health information secure and private. I agree to allow the use of email or text messages for communication regarding health matters. I will inform the Practice if I change to a new GP Practice or change address or contact details including my email address and mobile phone number. Text messages are generated using a secure facility. I understand they are transmitted over a public network onto a personal telephone and as such may not be secure. However, the Practice will not transmit any information which would enable an individual patient to be identified. I acknowledge that appointment reminders by text are an additional service & that these may not take place on all occasions, and that the responsibility of attending appointments or cancelling them still rests with me.

Name

This field is for validation purposes and should be left unchanged.

Phone

This field is for validation purposes and should be left unchanged.

We would like you to think about your recent experiences of our service.

Please can you tell us why you gave your answer?

This field is for validation purposes and should be left unchanged.

Hendon Way Surgery

Online Registration – Adult

Patient details

Please help us trace your previous medical records by providing the following information