New Patients The Red House Surgery is currently accepting new patients living within our catchment area. * Under 16 Registration Form Change of Details Temporary Patient Are you an Anglia Ruskin Student? Yes – I am a student No – I would like to register with Red House Surgery Title Mr Mrs Miss Ms Dr Other NHS Number Optional https://www.nhs.uk/find-nhs-number/what-is-your-nameFirst Names (As written on official documents) First Middle name (As written on official documents) Middle Optional Please put your middle name if you have.Surname (As written on official documents) Last Previous Surname Previous Surname Optional Date of Birth DD slash MM slash YYYY Gender (At birth) Male Female EthnicityWhite – BritishWhite – IrishWhite – Irish TravellerWhite – TravellerWhite – Gypsy/RomanyWhite – PolishWhite – OtherAsian or Asian British – IndianAsian or Asian British – PakistaniAsian or Asian British – BangladeshiAsian – OtherBlack or Black British – CaribbeanBlack or Black British -AfricanBlack or Black British – SomaliBlack or Black British – NigerianBlack or Black British – OtherMixed – White & Black CaribbeanMixed – White & Black AfricanMixed – White & AsianMixed – OtherEthnic – ChineseEthnic – FilipinoEthnic – OtherI do not wish to discloseFirst Spoken Language Town and Country of Birth Cambridge Address (please include a flat/room number) Street Address Optional Address Line 2 Optional City Optional Postcode Optional Mobile (UK Only)Landline (UK Only) OptionalEmail Address Optional Consent to receive SMS notification for clinical services Yes Optional No Optional Consent to receive EMAIL notification for clinical services Yes Optional No Optional Please help us trace your previous medical records by providing the following information. N/A – If this: is the first registration with the GP:Your previous address in the UK Street Address Address Line 2 City Postcode Name of previous GP practice while at that address in the UK Address of previous doctor in the UK Street Address Address Line 2 City Postcode Are you from abroad? Yes No If you are from abroad:Date you first came to live in the UK Day Month Year Please add your date of birth if you were born in the UKYour first address where registered with a GP Street Address Optional Address Line 2 Optional City Optional Postcode Optional If previously resident in UK, date of leaving Day Optional Month Optional Year Optional NOT Normally Resident in UK I am not ordinarily a resident in the UK Optional European Economic Area (EEA) CountryFor a list of EEA countries visit: www.gov.uk/eu-eeaDo you live in another EEA country, or have moved to the UK to study or retire, or live in the UK but work in another EEA member state? Yes Optional No Optional DemographicsMarital StatusSelect…Single, never marriedMarriedCivil PartnershipDivorcedWidowedSeparatedWhich of the following options best describes you?Select…Heterosexual or StraightGay or LesbianBisexualPrefer not to sayIn another waySeparatedSex and gender identity – Which one of the following best describes how you think of yourself?Select…Male (including trans men)Female (including trans women)Non-binaryPrefer not to sayIn another waySeparatedIs your gender identity the same as the gender you were given at birth? Yes No Prefer not to say Please specify the ethnic group you consider you belong toSelect…EnglishWelshScottishNorthern IrishGypsy or IrishTravellerAny other White backgroundWhite and Black CaribbeanWhite and Black AfricanWhite and AsianAny other Mixed / Multiple ethnic backgroundIndianPakistaniBangladeshiChineseAny other Asian backgroundAfricanCaribbeanAny other Black / African / Caribbean backgroundArabAny other ethnic groupPrefer not to sayWhat is your main religion?Select…No religionChristian (including Church of England, Catholic, Protestant, and all other Christian denominations)BuddhistHinduJewishMuslimSikhOther religionCommunication NeedsDo you speak English? Yes No Do you read English? Yes No What is your main spoken language? Are you a British Sign Language user? Yes No DisabilityDo you have an impairment, health condition or learning difference that has a substantial or long term (over a year) impact on your ability to carry out day to day activities? (Tick all that apply) No known impairment, health condition or learning difference Optional A long standing illness or health condition such as cancer, HIV, diabetes, chronic heart disease, asthma, or epilepsy Optional A mental health impairment, such as depression, schizophrenia or anxiety disorder Optional A physical impairment or mobility issues, such as difficulty using your arms or using a wheelchair or crutches Optional A learning difficulty Optional Neuro-diverse e.g. dyslexia, dyspraxia or AD(H)D Optional Deaf or hearing impaired Optional Blind or have a visual impairment uncorrected by glasses Optional An impairment, health condition or learning difference that is not listed above Optional Prefer not to say Optional Do you have any specific information or communication needs? If so, please specify how we can meet these for you (e.g. large print, Braille, easy read communications) OptionalArmed ForcesHave you served in the UK Armed Forces and/or been registered with a Ministry of Defence GP in the UK or overseas? Yes Optional No Optional CarersDo you have caring responsibilities? None Optional Primary carer of a child/children (under 18) Optional Primary carer of disabled child/children Optional Primary carer of disabled adult (18 and over) Optional Primary carer of older person Optional Secondary carer (another person carries out the main caring role) Optional Prefer not to say Optional Do you have a carer? Yes Optional No Optional Emergency ContactFull name First Last Relationship to you Contact NumberAre they your next of kin? Yes Optional No Optional Health QuestionnaireHeight (centimeters) Weight (kilograms) Smoking Status Current Smoker Ex Smoker Never Smoked How many cigarettes per day? Ex Smoker / Never Smoked = 0Alcohol ConsumptionThis is one unit of alcohol: Half pint of regular Beer/Lager/Cider 1 small glass of wine 1 single measure of spirits 1 single measure of aperitifs 1 small glass of sherry Each of these is more than one unit: Pint of regular Beer/Lager/Cider (2 Units) Pint of Premium Beer/Lager/Cider (3 Units) Alcopop or can/bottle of regular Lager (1.5 Units) Can of Premium Lager/Strong Beer (2 Units) Can of super strength lager (4 Units) Glass of wine (2 Units) Bottle of wine (9 Units) How many units of alcohol do you drink on a typical day when you are drinking? 1-2 3-4 5-6 7-9 10+ How often have you had 6 or more units if female, or 8 or more if male, on a single occasion in the last year? Never (0) Less than monthly (1) Monthly (2) Weekly (3) Daily or almost daily (4) How often do you have a drink containing alcohol? Never (0) Monthly or less (1) 2-4 times per month (2) 2-3 times per week (3) 4+ times per week (4) Do you have any significant family history we should be aware of? OptionalMedical HistoryMajor IllnessesPlease include dates.Past Operations OptionalPlease include dates.Family History IllnessesPlease include dates.Current MedicationAllergiesDo you have any allergies? Yes No Please specify what you are allergic to, what happens and when you had your first reaction. OptionalPlease include dates. Immunisation HistoryIf you received any covid vaccination abroad, please state: Date, vaccine, batch number, which arm, dose and from which countryPlease list any immunisations/vaccinations you have had OptionalPlease include dates.Important Registration InformationFor anyone aged 16 and over, we offer online services for appointment booking and repeat prescription ordering. This is the quickest and easiest way to order your medication. Once registered, you will also be able to view your summary record, detailing current medication, allergies and vaccinations. You will soon receive an email from the practice with your log in details. These are confidential: It is your responsibility to ensure they can be received securely by email. Prescriptions are sent electronically to your nominated pharmacy. We will automatically nominate the pharmacy closest to your post code as part of your registration. If you prefer to use a different chemist please contact the practice to sign up for the Electronic Prescribing Service.Summary Care RecordThis record will contain summary information about any medicines you are taking, allergies you suffer from and any bad reactions to medicines you have had to ensure those caring for you have enough information to treat you safely. Your Summary Care Record will be available to authorised healthcare staff providing you with care anywhere in England, but they will ask your permission before they look at it. This means that if you have an accident or become ill away from home, healthcare staff treating you will have immediate access to important information about your health.Do you consent to having a Summary Care Record? YES – Express consent for medication, allergies and adverse reactions only. OR Optional YES – Express consent for medication, allergies, adverse reactions AND additional information. Optional NO – I do not want a summary care record. Optional Your Medical Information – Sharing Your DataUnder the General Data Protection Regulations (GDPR), we have a responsibility to keep your medical records confidential. We need your consent to share this with other authorised health professionals involved in your care or in planning your care. You can find more information on the website at nhs.uk/your-nhs-data-matters. Please see the privacy notice on our website for more information on how your data is held and used by the practice. The NHS wants to make sure you and your family has the best care now and in the future. Your health and adult social care information supports your individual care. It also helps us to research, plan and improve health and care services in England. There are very strict rules on how this data can and cannot be used, and you have clear data rights. We are committed to keeping patient information safe and will always be clear on how it is used. You can choose whether or not your confidential patient information is used for research and planning. If you do not wish your information to be used in this way please opt-out by visiting nhs.uk/your-nhs-data-matters or by calling 0300 303 5678. The practice is unable to record this for you. This record will contain summary information about any medicines you are taking, allergies you suffer from and any bad reactions to medicines you have had to ensure those caring for you have enough information to treat you safely. Your Summary Care Record will be available to authorised healthcare staff providing you with care anywhere in England, but they will ask your permission before they look at it. This means that if you have an accident or become ill away from home, healthcare staff treating you will have immediate access to important information about your health.NHS Organ Donor registrationFor more information on organ donation please visit: www.organdonation.nhs.uk If you would like to join the NHS Blood Donor Register as someone who may be contacted and would be prepared to donate blood, please visit their website on: www.blood.co.uk or call direct on 03001232323.Pharmacy NominationPharmacy Nomination OptionalSelect…Boots Newmarket roadBoots Petty CuryBoots Grafton CentreLloyds Arbury CourtMilton Road PharmacyRowlands Histon roadTesco (Milton)Lloyds (Inside Sainsburys)AsdaOther, please state name and post codePlease Specify Optional SignatureClarification I certify that the information I have provided is correct and consent to my personal and medical information being used as stated above. Optional Signature