About this form
Fields marked with an asterisk are compulsory.
Confidentiality
By using this form you will be sending information about yourself across the Internet. Whilst every effort is made to keep this information secure, you should be aware that we cannot offer any guarantees of absolute privacy.
Also, by sending this form you are indicating your agreement that the surgery may contact you by email or telephone to discuss the information contained in this form.
If either of these points concerns you or you disagree in any way then you should use another method of notifying us of your change of contact details.
Personal information
Personal information retained on this system is stored in a secure data centre located in the UK and is treated as confidential.
Your contact details
Information about you
Do you need an interpreter?
Ethnic background
Proof of identity and address provided
Medical conditions
Have you ever suffered from? (tick as appropriate)
Are you registered disabled?
Are you allergic to any medicines?
Have you ever refused treatment/screening of any kind?
Mental health
Have you ever suffered from any of the following? (tick as appropriate)
Carers
Carers
Do you have a carer?
Are you a carer?
Living Wills
A Living Will is documentation regarding your personal wishes in respect of medical intervention at the time of serious illness.
Do you hold a Living Will?
Women
Have you ever had a cervical smear?
Smoking
Do you smoke
If 'No', have you ever smoked?
Alcohol
1 drink = 1/2 pint of beer or 1 glass of wine or 1 single spirits