Prescriptions

Phone

This field is for validation purposes and should be left unchanged.

Date of Birth(Required)

Address (and postcode)(Required)

Recent BP Reading (if known)

Preferably from the past month. If you don't have a recent reading, please contact the practice.

What is the name of the contraception you are using?(Required)

Please specify(Required)

How many per day?(Required)

When did you stop smoking?(Required)

Please specify(Required)

Which family member?(Required)

Is there anything else you would like to tell us or would like to know about your contraception?

We can text you if a prescription is issued. If you are happy to receive a text, enter your mobile number here.

Phone

This field is for validation purposes and should be left unchanged.

Please do not use this form, you must complete a temporary registration form.

Date of Birth*

Current Address and Postcode*

Community Health Index (CHI) Number*

Registered District of Birth

Please help us trace your previous medical records by providing the following information

Name of Previous GP*

Address of Previous GP*

Your Previous Address

This is usually the address when you were last registered with a GP

Your first UK address*

Date you first came to UK

Address and Postcode before enlisting*

Service or Personnel Number*

Please upload photo ID and proof of address*

Drop files here or

Max. file size: 128 MB.

Electronic Signature (Type your full name here)*

By completing the section above, I hereby sign this form electronically

NHS Organ Donor Registration

NHS Blood Donor Registration

My preferred address for donation is:

Allergies/Medicines

Are you allergic to anything such as Penicillin or Aspirin?

Please list the names and doses of any medicines you are taking at present

What is your preferred Pharmacy for prescriptions?*

Medical History

Please enter any previous significant illness, accident or operations with the year they occurred

Family History

Please give details of any serious illness any of your relatives have suffered from especially your parents, brothers and sisters. If any of your parents, brothers or sisters have died could you please say how old they were when they died and what was the known cause of death

Consumption (units/week)*

Please state your relationship to them*

Dear Patient,

In order to improve the information available to the out of ours service (GMEDS), Ambulance Service and Secondary Care (Hospital) it is now possible for some of the information held in GP records to be made available electronically to them by Key Information Summary (KIS). In order for this to happen, we need your permission to allow us to switch the transfer on. The information can only be accessed by those clinicians who require it. The information includes up to date medication lists and major health issues. This information is very important in an emergency and could reduce delays in treatment. If you are happy for this information to be shared, please complete the relevant section below

For patient

I give my permission for my records to be shared for the use of KIS

Date of Birth*

Date

For parent if applicable

I give my permission for the records of ............, for whom I am the parent, to be shared for the use of KIS

Parent Date of Birth

Date

For guardian if applicable

I give my permission for the records of ..........., for whom I hold Welfare Power of Attorney/Guardianship, to be shared for the use of KIS

Guardian Date of Birth*

Date

Registration for ordering prescriptions online

Date

Comments

This field is for validation purposes and should be left unchanged.

𝐖𝐞𝐬𝐭𝐛𝐮𝐫𝐧 𝐌𝐞𝐝𝐢𝐜𝐚𝐥 𝐆𝐫𝐨𝐮𝐩 𝐋𝐋𝐏

Prescriptions

Opening Times

Useful Links

NHS A-Z Conditions

Find Local Services

Live Well

𝐖𝐞𝐬𝐭𝐛𝐮𝐫𝐧 𝐌𝐞𝐝𝐢𝐜𝐚𝐥 𝐆𝐫𝐨𝐮𝐩 𝐋𝐋𝐏

Prescriptions

Opening Times

Useful Links

NHS A-Z Conditions

Find Local Services

Live Well

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