Online form- Registration | Chase Cross Medical Centre

Personal Details

Title *

First

Middle

Last

Date of Birth *

Telephone number

NHS NUMBER *

Mobile number

UK Address *

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Email *

Email

Confirm Email

Marital status *

Sexual Orientation *

Note: This information is used to monitor equality between groups of people of different sexual orientations. Equality monitoring helps make sure that everyone is treated fairly.

Is your gender the same as the sex you were registered at birth?

Yes
No

If No – Birth Gender? *

Housing Status *

Inadequate
Need help

Social Status

Isolation
Social Support

Employment Status *

Ethnic Origin *

Next of Kin – Family Members Details *

First

Last

Next of Kin Full name

Mobile number

Relationship *

Email *

Summary Care Record

I wish to have access to the following online services *

I express consent for medication, allergies and adverse reactions to be shared
I express dissent that I do not want a Summary Care Record
Booking appointments online
Requesting repeat prescriptions online
Accessing limited medical information

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Medical History

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Previous Doctor (GP / Family Doctor) Name

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Practice Name

Field #127 (copy)

Telephone No

Address

Address Line 1

City

State / Province / Region

Postal Code

Country

Smoking Status *

Never smoked tobacco
Ex-smoker
Smoker

Weight *

Height *

If you are a current smoker how many cigarettes do you smoke per day?

Selected Value: 0

To improve your health, we recommend that you stop smoking. If you are interested in giving up smoking please speak to a member of staff.

Last blood pressure reading

Date of last smear

Have you had your Meningitis C Vaccination? *

Yes
No

Have you had your MMR Vaccine (measles/mumps/rubella)? *

Yes
No

Alcohol intake

How many units of alcohol do you drink per week?

1.6 units: One Glass of Wine (1.25ml)
2.3 units: One Glass of Wine (1.75ml)
1 unit - ½ pint beerllarger/1 pub meas ure of spirit

How often do you have 8 (men) 16 (women) or more drinks on one occasion?

ONLY ANSWER QUESTIONS 2, 3 & 4 IF YOUR ANSWER TO QUESTION 1 IS MONTHLY, WEEKLY OR DAILY

How often in the last year have you not been able to remember what happened when drinking the night before?

How often in the last year have you failed to do what was expected of you because of drinking?

Has a friend /relative /doctor /h ealth work er been concerned about your drinking or advised you to cut down?

NIA
No (0)
Yes , but not in the last year (2)
Yes, during the last year (3)

Chronic conditions

Do you have any Chronic Conditions that you suffer from and their date of onset?

Women Only - Please give details of any pregnancies with dates

If you do suffer from any chronic conditions how are you followed up? With your GP or Practice nurse?

Yes
No

At the Hospital?

Yes
No

Please give us details of any allergies that you have to medication or other items (i.e. nuts, latex etc):

Family Medical History

Please give details of your family medical history Tick the relevant boxes and say who the history relates to (only need for immediate family members. i.e. parents and siblings

GENERAL

Do you have a disability?
Are you registered disabled?
Are you registered blind or partially sighted?

Single Line Text

If yes, please state details

Important Notes:

➢ Please note that you will be unable to see a GP until your registration is complete. This includes the processing of all completed forms and having an appointment to see the Doctor for a New Patient Health Check.

➢ If you are going to require repeat medication immediately after registration without seeing a doctor, from your previous GP and pass it to the receptionist with your written repeat prescription request. We will be unable to issue repeat prescriptions without an appointment with a doctor if this information is not provided.

➢ Please bring one ID proof (passport/full driving license) and one Address proof (Bank
statement/council tax bill/utility bill)

➢ Useful links
o CCG Website: https://northeastlondon.icb.nhs.uk/your-area/havering/
o NHS Covid-19: https://www.nhs.uk/covid-19-advice-and-services/
o NHS 111/ Emergency: https://111.nhs.uk/
o NHS.UK: https://www.nhs.uk/
o Department of Health and Social Care: https://www.gov.uk/government/organisations/department-of-healthand-social-care
o https://northeastlondon.icb.nhs.uk/
NHS North East London is responsible for planning and buying health services across north east London to meet our population’s needs, making sure all parts of the local health system work effectively together.

Surgery Website: http://iz1.7db.myftpupload.com/

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