Mayfair Doctors Registration Form

Mayfair Doctors Registration Form
Personal Details
Full Name*

First NameLast Name
Title : Mr, Dr, Miss, Ms, Mrs, etc*
Title you would like to be addressed by
Date of Birth*

DayMonthYear
Sex (for medical purposes) *
Details
Please provide details
Nationality
Address*

Street Address

Street Address Line 2

CityCounty / State

Postal / Zip CodeCountry
Phone Number*
E-mail*
If patient is child, then this section to be filled in with the details of parent or legal guardian.
Full Name

TitleFirst NameLast Name
Address, if different from above

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
G.P. Details
Would you like us to contact your G.P.?

YesNo
G.P. Name and Address
Emergency Contact
Full Name
Relationship
Address
Phone Number
Carer
Do you have a carer?
Name
Would you like them to deal with your health affairs here?
Personal Medical History
Have you ever suffered or do you suffer from
chronic illnesses?*
Comments
heart or chest problems?*
Comments
blood pressure problems?*
Comments
epilepsy fits, faints or blackouts?*
Comments
heart disease / heart attack*
Comments
diabetes?*
Comments
a stroke?*
Comments
allergies, hay fever or eczema?*
Comments
cancer or been treated for cancer before?*
Comments
blindness or glaucoma?*
Comments
depression or psychosis?*
Comments
Do you have any disabilities?*
Comments
Have you had an operation or are there any other medical conditions the doctor should know about?*
Please list
Please specify all drugs, medicines, tablets or pills that you take regularly:
Are you allergic to any medication (e.g. penicillin)?*
Please list
Your Health
Do you smoke?*
How many cigarettes per day?
Are you an ex smoker?*
Date stopped:
Do you drink alcohol?*
How many units per day 1 unit = 1 glass of wine or 1 pint of beer or 1 measure of spirit
Family Medical History
Is there anyone in your family who has had:

Heart disease / heart attackStrokesBlood PressureDiabetesAsthmaCancerAny chronic illness
Women only
Have you had a cervical smear test in the last three years?
Date and result:
Have you had a hysterectomy?
Date and result:
Do you take the contraceptive pill?
Which one:
Do you have a coil/IUD fitted?
When and what type:
Are you pregnant?
Any past pregnancies
Please list the years:
Any complications during pregnancies
Please list:
I have carefully read and understood this questionnaire and Terms and Conditions and filled this form to the best of my knowledge.

Terms and Conditions

Fees

I am aware that this is a private health clinic, and I will be charged a consultation fee, and any additional treatments or tests will incur further charges, which I will be made aware of before undertaking. If I am unsure about costs of my treatment, I will ask for clarification from a member of staff. I will pay the fees I have incurred prior to leaving the clinic. I understand there is no obligation to any treatment or tests after the initial consultation.
I agree with the above statement.*
How are you paying?*
Would you like us to contact you with any news or information which may be of interest to you?*
Should be Empty: