Registrations - Northiam and Broad Oak Surgery

NHS Number

To register you will need your NHS number. If you do not know your NHS number there is an online service which will help you find it. Click Here.

I am filling this form on behalf of:

As you are registering on a patients behalf please provide your name

Title First Middle Last

Name

Title First Middle Last

Previous Surname

Last Optional

Your Address

Address Line 1 Address Line 2 Town Post Code

Date of Birth

Ethnicity

Language

Country of birth

Home Phone Number Optional

Mobile Phone Number Optional

Email Address Optional

Please provide details of your previous address and the GP with whom you were registered. This allows us to ensure your records are transferred on registration

Your Previous Address

Address Line 1 Address Line 2 Post Code Country

Name of Previous GP Surgery

Are you joining the surgery from abroad?

No Optional

Yes Optional

Date you came to the UK

If previously resident in the UK, date of leaving Optional

Address at which you first registered with a GP

Address Line 1 Optional Address Line 2 Optional City Optional Post Code Optional

Are you from the armed forces

No Optional

Yes Optional

Address before enlisting

Address Line 1 Address Line 2 City County/State Post Code Country

Service Number

Enlistment Date

Discharge Date

Power of Attorney and discussion about your health

Do you have a lasting Power of Attorney?

No

Yes, if you have a Power of Attorney then please provide a copy

Permission for family members or others to speak to the doctor on your behalf

If you wish, or need support, you may nominate others (carers, relatives, friends) who can talk to the surgery on your behalf.

No

Yes

Person to be Permitted Access

First Last

Relationship

Contact Number

Summary Care Record

The summary care record consists of basic information such as your date of birth and address, details of allergies, current prescriptions and bad reactions to medicines.

Additional information can be included to your SCR with your permission. It will include:

Your long term health conditions – such as asthma, diabetes, heart problems or rare medical conditions.

Your relevant medical history – clinical procedures that you have had, why you need a particular medicine, the care you are currently receiving and clinical advice to support your future care.

Your healthcare needs and personal preferences – you may have particular communication needs, a long term condition that needs to be managed in a particular way, or you may have made legal decisions or have preferences about your care that you would like to be known.

Immunisations – details of previous vaccinations, such as tetanus and routine childhood jabs.

Please note: specific sensitive information such as any fertility treatments, sexually transmitted infections, pregnancy terminations or gender reassignment will not be included, unless you specifically ask for any of these items to be included.

Do you consent to having additional information included in your Summary Care Record?

If you wish, or need support, you may nominate others (carers, relatives, friends) who can talk to the surgery on your behalf.

No

Yes

ID and VerificationWe will need to validate your Identify documents before registration. You can upload these below or alternatively bring these into the surgery.

Passport Optional

Dirving Licence Optional

Utility Bill Optional

Other Optional

Upload ID Verification Documents OptionalChoose the files you have selected to upload

Drop files here or

Max. file size: 50 MB, Max. files: 3.

Patient Registration

Summary Care Record