Adult new patient registration

Patient’s Details

Please specify:

Surname: *

Previous Surnames:

First Name(s) *

NHS Number:

How to find your NHS Number

What sex do you identify with? *

Male

Female

Intersex

Does your gender identity differ from that which was assigned at birth? *

Yes, Trans male to female

Yes, Trans female to male

Yes, Non binary

No

Please state your sexual orientation: *

Heterosexual or straight

Homosexual or gay

Bisexual

Other

Please specify your sexual orientation: *

Do you currently have a fixed address? *

Yes

No

Hall Green Health will continue to register you but they will put your address as the surgery’s address. As soon as you have an address please let us know as it helps us to get hold of you in regards to your care.

Do you live in a care home? *

Yes

No

Name of care home: *

Home Address: *

Postcode: *

Town of Birth: *

Country of birth: *

Preferred Phone Number *

Alternative Phone Number:

Work Phone Number:

Can we contact you by text? *

Yes

No

Can we contact you by email? *

Yes

No

Have you ever been registered with Hall Green Health before? *

Yes

No

Do you have any information or communication needs such as large print or specific coloured paper? *

Yes

No

Please specify: *

Are you happy to travel to the surgery if necessary? *

Yes

No

How would you define your mobility? *

Independently mobile

Mobile with aids

Dependent / housebound

Ethnicity

Please specify the ethnic group you consider you belong to: *

*

English / Welsh / Scottish / Northern Irish / British

Irish

Gypsy or Irish Traveller

Any other White background

Prefer not to state

*

Asian and White

Black African and White

Black Caribbean and White

Another Mixed / Multiple ethnic background

Prefer not to state

*

African

Caribbean

Any other Black background

Prefer not to state

*

Arab

Any other ethnic group

Prefer not to state

Please state: *

Do you speak English? *

Yes

No

Do you read English? *

Yes

No

Is English your first language? *

Yes

No

What is your first language? *

Do you need an interpreter? *

Yes

No

Emergency Contact

Full Name: *

Relationship to you: *

Phone Number: *

Are they your Next of Kin? *

Yes

No

Do you give us permission to discuss your medical records with them? *

Yes

No

Allergies

Do you have any allergies? *

Yes

No

Please specify what you are allergic to, what happens and when you had your first reaction:

Previous Details

Have you previously lived at another UK address? *

Yes

No

Please provide your previous UK address: *

Please include postcode.

Have you been previously registered with another surgery in the UK? *

Yes

No

Name of Previous GP: *

Address of previous GP: *

If you are from abroad

Date you came to live in the UK:

Please use this date format: DD/MM/YYYY.

If you are under 3 years old you must have a named health visitor. If you do not have one please call the health visitors on 0121 466 4820.

If you are returning from abroad

Previously been a resident in the UK

Date you left the UK:

Please use this date format: DD/MM/YYYY.

Date you returned to the UK:

Please use this date format: DD/MM/YYYY.

Carers

Do you have a carer? *

Yes

No

Name of carer:

Phone Number:

Address:

Do you give us permission to discuss your medical record with your carer?

Yes

No

Are you a carer for someone? *

Yes

No

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Patient’s Details

Ethnicity

Emergency Contact

Allergies

Previous Details

If you are from abroad

If you are returning from abroad

Carers