Montpelier Surgery
Family Doctor Services Registration
Please fill out all fields in BLOCK CAPITALS
Title_______________
Date of Birth
d
d
Surname____________________________________________
m
m
y
y
First Names_____________________________
Town of Birth_____________________
Country of Birth_______________________
Current Address
Flat No: (if applicable)________
House Number______
Postcode_____________________
Street Name_____________________________________________
Telephone Number
Please fill this section out as accurately as possible as we use it to locate your medical records.
Your Previous Address
Postcode_____________
If you are from abroad please give the date
you first came to live in the UK. ___/___/__
Name and Address of Previous Doctor
If Previous Resident in UK date of leaving
___/___/___
And date returned to live in UK ___/___/__
Your NHS Number
Other Contact Details and Consents
Telephone Number__________________________ Mobile Number_________________________________
The Montpelier Surgery contacts their patients regarding appointment times and pathology results by SMS text
message . All contact information regarding our patients is held as strictly confidential and will never be passed
on to any third party. If you do not wish to be contacted by these methods please indicate below. If you leave
this blank then you will automatically be opted IN.
I DO CONSENT
I DO NOT CONSENT
Occasionally where appropriate we might contact you via email. If you would like to be contacted via this method please add your email address here _______________________________________
Online Services
We offer an online service for making and cancelling appointments as well as ordering repeated medication. If
you would like to use these please indicate. If left blank you will automatically be opted OUT.
I WOULD LIKE TO BE REGISTERED
I WOULD NOT LIKE TO BE REGISTERED
Additional Details
What is your main spoken Language?_______________________ Would you require an Interpreter? YES/NO
Next of Kin—Please give details of whom to contact on your behalf in an emergency.
Name_______________________________ Relationship to you __________________________________
Contact Number__________________________________________ Date of Birth___________________
www.montpeliersurgery.co.uk
Version 1.8
Lifestyle
Marital Status :
Single
Married
Occupation: Employed
Divorced
Unemployed
Living with Partner
Retired
Widowed
Other: (please specify)________________________
If you are Employed please state your occupation (eg Teacher)___________________________
Do you Smoke? YES
NO
Are you an Ex-Smoker? YES
If YES please specify amount _____ Per Day
NO
If YES please specify amount _____ Per Day
I have never smoked tobacco
Smoking Cessation offered
Alcohol Screening - please tick to indicate answer
How many units do you drink per week? _________ units (1 unit = 1/2 pint of beer/ 1 med glass wine/ 1 spirit measure)
MEN: How often do you have EIGHT or more units on one occasion? Never ( ) Monthly ( ) Weekly ( ) Less than
Monthly ( ) Daily or almost daily ( )
WOMEN: How often do you have SIX or more units on one occasion? Never ( ) Monthly ( ) Weekly ( ) Less than
Monthly ( ) Daily or almost daily ( )
How often during the last year have you been unable to remember what happened the night before because you had
been drinking? Never ( ) Monthly ( ) Weekly ( ) Less than Monthly ( ) Daily or almost daily ( )
How often during the last year have you failed to do what was normally expected of you because of drinking? Never ( )
Monthly ( ) Weekly ( ) Less than Monthly ( ) Daily or almost daily ( )
In the last year has a relative or friend, or a doctor or other health worker been concerned about your drinking or
suggested you cut down? No ( ) Yes, on one occasion ( ) Yes, on more than one occasion ( )
Medical and Family History
Please indicate below if you or a member of your family have suffered from any of the conditions listed below
Condition
You (Date of Diagnosis)
Heart Attack / Angina/ Other Chronic Heart Disease
Heart Failure
High Blood Pressure requiring medication
Stroke ( )
Transient Ischaemic Attack (
Diabetes: Type 1 (
)
)
Type 2 ( )
Asthma requiring inhalers
Chronic Obstructive Pulmonary Disease (COPD)
Epilepsy
Hypothyroidism
Chronic Kidney Disease (Please indicate Stage 1-5)
Depression requiring medication
Schizophrenia/Bipolar/ other psychoses
Cancer
Dementia ( Alzheimer’s / Parkinson’s)
www.montpeliersurgery.co.uk
Family (Date of Diagnosis)
Other Information
Are you currently taking any medication? If so please specify, please be aware that if you need medication you must
see a GP first
Do you have any allergies? Please give details
Your Pharmacy
The Electronic Prescription Service (EPS) will automatically send your prescription to the Pharmacy that you nominate here
Nominated Pharmacy:
___________________________________________
Feedback
The practice is always keen to hear your feedback on any aspect of our service. Please use the online feedback
form at www.montpeliersurgery.co.uk, speak to the Practice Manager, or to any member of our team.
For those keen to get more involved we are setting up a “Patient Reference Group”. We know that it is hard for patients to come in to the surgery for meetings so we would like to contact you by email or by post. We may also invite
you to meetings but of course your attendance would not be compulsory. We would like to ask your opinion on
changes to your surgery an give you the opportunity to become more involved if you would like to do so. There is no
time commitment involved!
Interested?... Please email the Practice at [email protected]. Please include in your reply any questions
you think we should ask in a Patient Survey.
Patient Signature___________________________________________
Signature On Behalf of Patient ___________________________
Name____________________
Relationship to Patient___________________________
Date_______/______/_______
NB. We cannot process your registration unless a member of staff has seen photographic
ID (e.g. Passport/Driving Licence) and a Proof of Address (which should be dated in the
last 3 months)
www.montpeliersurgery.co.uk
Gender
Male
Do you now, or have you ever considered yourself Transgender?
Yes
Female
Other
No
I do not wish to disclose this information
I would describe my ethnic origin as
Asian
Mixed
Asian British
Bangladeshi
Indian
Pakistani
Any other Asian background
Black
Black British
African
Caribbean
Sudanese
Any other Black
background
……………………………….
Other Ethnic Group
Asian & White
Asian & Black
African
Asian and Black Caribbean
White & Black African
White and Black Caribbean
Any other mixed
background
Chinese
Turkish
Arab
Japanese
Any other ethnic group
(please give details)
………………………………
……………………………………...
White
British
Irish
Gypsy
Traveller
Polish
Portuguese
Any other White
background
……………………………………...
I do not wish to disclose this
....................................
Please select the option which best describes your sexual orientation
Lesbian
Gay
Bisexual
Heterosexual
Unsure
Other (please state)
I do not wish to disclose this
…………………………………………………………..
Please indicate your religion or belief
Agnostic
Atheism
Buddhism
Christianity
Hinduism
Islam
Jainism
Judaism
Pagan
Sikhism
Other
………………………...............
I have no particular faith
I do not wish to disclose this
Do you consider yourself to have a disability or long term limiting condition?
Yes
No
I do not wish to disclose this
Please state the type of impairment which applies to you. People may experience more than one type
of impairment, in which case you may indicate more than one. If none of the categories apply, please
mark ‘other’.
Physical Impairment
Learning Disability / Difficulty
Sensory Impairment
Long-term illness
Mental Health Condition
Other (please state)
………………………………………………….
Are you a Military Veteran ?
Yes
No
Are you a carer?
Yes
No
I do not wish to disclose this
If yes do you care for …….?
Parent
Child
Other family member
Partner / spouse
Friend
Other ……………………………………………………..
What age are you?
For Office Use ONLY
You must see two forms of ID:
1)
Photographic ID
2)
Proof of residency in the Practice Area
i.e. proof of address
Tick below to indicate which you have seen
British Passport valid and seen?
EU Passport valid and seen?
Other valid Passport seen and photocopied
Proof of address within catchment area
Offered New Patient Medical
Patient informed of registration process