YMG2020/1A New Patient Registration Form

New Patient Registration

Complete this form to register as a patient with York Medical Group
First Name *
Surname *
Date of Birth *

Day Month Year
NHS Number
Optional
Gender *
Town & Country of Birth *
Address *

Street Address

Street Address Line 2

City
Postcode *
YES - POSTCODE IN AREA
NO - POSTCODE IS OOA
POSTCODE SCORING
Preferred Telephone Number *
This can be a mobile or landline telephone.
Additional Number
Optional: Please provide a secondary contact number
Email Address
Next of Kin *
NOK: Relationship
Contact details *
Are you a carer?

Yes (Informal/Unpaid) Yes (Occupational/Paid) No
Do you have a carer?

Yes No
Armed Forces
Address before enlisting

Street Address

Street Address Line 2

City

Postal / Zip Code
Service or Personnel number
Enlistment Date

Day Month Year
Discharge Date

Month Day Year
(if applicable)
Housing *
Select if you are from the UK or abroad *

UK Abroad
Previous UK Address *

Street Address

Street Address Line 2

City

Postal / Zip Code
Date you first lived at this address *

Month Day Year
(approximate)
Name of Doctor or Surgery when at that address *
Address of Doctor or Surgery *

Street Address

Street Address Line 2

Post Code
Date arrived in the UK

Day Month Year
Expected date of leaving the UK

Day Month Year
Date
Your first UK address where registered with a GP (only if you have previously registered with a GP)

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
If a previous resident in UK, date you left

Day Month Year
Signature *

By signing you agree that the information submitted is Clear
All about you

Please answer to the best of your knowledge
Medical History

Asthma COPD Epilepsy Heart Disease Heart Failure High Blood Pressure Diabetes Kidney Disease Stroke Depression Underactive Thyroid Cancer
Family History

Asthma COPD Epilepsy Heart Disease Heart Failure High Blood Pressure Diabetes Kidney Disease Stroke Depression Underactive Thyroid Cancer
Do you smoke?

Yes No Used to smoke
How many units do you drink in an average week?
Height
In CM
Weight
in KG
Do you require an Interpreter?

Yes No
Do you have any additional communication needs?

Yes No
Please select your additional communication need
First Language
Ethnicity *
Religion
Consent to Share Information

Summary Care Record (SCR) - this is an electronic record which contains information about the medicines you take, allergies you suffer from and any bad reactions to medicines you have had. Having this information stored in one place makes it easier for healthcare staff to treat you in an emergency, or when your GP practice is closed. Do you give your permission for us to share the following data?
Your medications, allergies & adverse reactions? *

Yes No
Your medications, allergies & adverse reactions & additional information? *

Yes No
Important Information

It is practice policy to share information that is recorded on your clinical record with other clinical staff that you are under the care of to ensure the best care is provided to you. For further information please ask for an information leaflet or visit www.nhscarerecords.nhs.uk/carerecords.
Do you consent for us to share your medical records with other medical service you may be using i.e. District Nurse Teams, Podiatry or Dieticians? *

I agree to opt in I DO NOT agree
Do you give explicit consent for us to CONTACT YOU via text SMS message with test results and appointment reminders? *

Yes No
Would you like to be involved in our Patient Participation Group?

Yes No
OPTIONAL: Do you use ELECTRONIC PRESCRIBING? If yes, please inform us of your nominated pharmacy
OPTIONAL: If you needed an organ or blood transplant would you have one?

If so, please help those in need of a transplant by opting to donate organs, tissue and/or blood.

Click here to opt in to donate blood

Click here to opt in to donate organs/tissue

Click here to opt out of donating organs/tissue
OPTIONAL: Access to your Online Medical Records
York Medical Group offers the facility for patients to view online, export or print their full clinical summary from the 1st April 2016. To register for online access you will be required to provide a copy of your photo identification such as a Driving Licence or UK Passport.

Click Here: For more information about access to online records

Click Here: To request online access to your medical records
HIDDEN SECTION: ANSWER

This section will be hidden to patients. It is used for coding calculations only.
GMS1 CODE
INFORMED OF NAMED GP
PATIENT ALLOCATED NAMED GP
Are you a carer?
Do you have a carer?
Do you require an Interpreter?
Armed Forces
Housing
Do you smoke?
How many units do you drink in an average week?
Height
Weight
First Language
Additional Communication Needs
Ethnicity
Religion
Your medications, allergies & adverse reactions
Your medications, allergies & adverse reactions & additional information?
Do you consent for us to share your medical records with other medical service you may be using i.e. District Nurse Teams, Podiatry or Dieticians?
Do you give explicit consent for us to CONTACT YOU via text message?
Would you like to be involved in our Patient Participation Group?
Should be Empty:

New Patient Registration

All about you

Consent to Share Information

OPTIONAL: Access to your Online Medical Records

HIDDEN SECTION: ANSWER