Patient Information Form

Please complete both this patient information form and the patient registration form. Both parts are required for registration at the surgery.

First Name

Last Name

Date of Birth

Marital Status

Ethnic Origin

First language

I require an interpreter

Religion

Contacts

Home Telephone Number

Mobile Telephone Number

Other Telephone NumberPlease state number type i.e. work, family member

Email Address

I consent to the surgery contacting me by SMS (text) message

I consent to the surgery contacting me by email

Occupation, or Name and Address of School

Next of KinPlease specify name, address, telephone number and relationship to you

Are you a carer?

If you answered yes to the previous question, please detail who you care for and what care you provide

I have a carer

Family History

If yes, please specify family member, age diagnosed and any details you think are relevant

List any illness you have had in the past or are taking regular medication for

Please list your regular medicationIf you do not take regular medications, please type 'none'.

Which local pharmacy do you want to have any prescriptions sent to?If you have your prescriptions sent straight to a pharmacy already, please specify this and any changes you would like to make.

I am currently under the care of a medical specialist

If you checked the box above, please give name, speciality and hospital, or any details that are relevant.

Are you allergic to any drugs or medicines? What was the reaction?Please state 'no allergies' if none known.

Alcohol Consumption

How often do you have a drink containing alcohol?

How many units of alcohol do you drink on a typical day of drinking?

How often have you had 6 or more units if female, or 8 or more units if male, on a single occasion within the last year?

If you require more information about my alcohol consumption, I am happy for the surgery to send me a further questionnaire

Smoking

Do you smoke or have you ever smoked?

If you answered yes, please give detailsPlease state whether you currently smoke and how many cigarettes you smoke per day. If you no longer smoke, please specify when you stopped smoking

Women's Health

What form of contraception do you use?Females only

When did you have your last cervical smear?Females only

I would like to be involved in your Patient Participation Group (2-3 emailed surveys a year and an opportunity to give your views to the surgery)This involves receiving 2-3 emailed surveys yearly and is a great opportunity to give your views and opinions to the surgery.

If moving surgeries locally, please state the reason

Sharing Medical Records

It is possible for other health organisations that use the same clinical system as us, such as the urgent treatment centre, to be able to see your health records. These records are not shared with anyone outside of healthcare organisations relevant to you.

I consent to the sharing of data recorded at the surgery with other organisations that may care for meYou can change your mind at any time.

I consent to the surgery viewing my data that has been recorded at other services that may have cared for meYou can change your mind at any time.

Please bring in two forms of identification:

1) Photo ID

2) Proof of address

When your registration has been accepted, you can make an appointment with the Practice Nurse for a 'New Patient Health Check'

Privacy Protection

Information submitted through secure forms is used only for the purposes of processing your request. We may be in touch with you in relation to the information submitted.

All Information submitted through secure forms is secured with a private key and is accessed over a secure connection by nominated staff. We have a strict confidentiality policy.

This information is not shared with any third party organisations.

This information is retained for up to 28 days.

I consent to my information being used for the purposes described above and wish to submit this online form to The Old Fire Station Surgery • 68a Portsmouth Road, Woolston, Southampton, SO19 9AN.

Learn more about our Privacy Policy and Terms of Use. Should you have any concerns about sending your personal details using the web, please use one of the alternative methods offered by our organisation.