WHMP Adult Care Home Resident Registration Form

Fields marked "REQUIRED" are compulsory.. You should only send this form if you are sure that you are eligible to join this practice. Sending this form will NOT automatically register you with the surgery. Sending this form does NOT guarantee or even imply that you will be accepted onto the practice register.

Last Updated: 04/10/2023

Patient Details

TITLE *

SURNAME *

FIRST NAME *

MIDDLE NAME(S)

PREVIOUS NAME(S)/SURNAME

DATE OF BIRTH *

BIRTH TOWN *

BIRTH COUNTRY *

NHS NUMBER

CURRENT ADDRESS *

POSTCODE *

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

PREVIOUS HOME ADDRESS *

NAME OF PREVIOUS GP PRACTICE

ADDRESS OF PREVIOUS GP PRACTICE

Contact Details

Please be aware we may leave a standard voicemail for you on the numbers provided. No private details will be disclosed in any messages left.

Clinicians may use SMS messaging to communicate with you regarding health issues, please indicate below whether you are happy to receive these messages.

MOBILE PHONE NUMBER (PLEASE PROVIDE HOME NUMBER IF NO MOBILE) *

HOME PHONE NUMBER

PLEASE INDICATE IF YOU WANT TO RECEIVE SMS MESSAGES CONTAINING PERSONAL INFORMATION *

I do want to receive messages containing personal information

I do not want to receive messages containing personal information

EMAIL ADDRESS

PLEASE INDICATE IF YOU WANT TO RECEIVE EMAILS FROM THE PRACTICE *

I do want to receive emails from the practice

I do not want to receive emails from the practice

Registering for the first time from Abroad?

ARE YOU REGISTERING FOR THE FIRST TIME FROM ABROAD?

Yes

FIRST DATE OF ENTRY TO THE UK

COUNTRY ARRIVING FROM

Registering Following Military Service?

ARE YOU REGISTERING FOLLOWING MILITARY SERVICE?

Yes No

Ethnic Origin and Main Language Spoken

PLEASE SELECT WHICH ETHNIC GROUP YOU BELONG TO *

OTHER ETHNIC BACKGROUND

DO YOU SPEAK ENGLISH?

Yes No

OTHER LANGUAGE(S) SPOKEN

DO YOU REQUIRE AN INTERPRETER?

Yes No

Next of Kin / Emergency Contact Details

NAME OF NEXT OF KIN *

RELATIONSHIP TO PATIENT *

CONTACT TELEPHONE NUMBER *

CAN WE CONTACT YOUR NEXT OF KIN IN THE EVENT OF AN EMERGENCY? *

Yes No

Your Health and Lifestyle

CURRENT WEIGHT

CURRENT HEIGHT

DO YOU HAVE ANY ALLERGIES? IF SO, PLEASE SPECIFY (E.G. ALLERGY TO PENICILLIN)

DO YOU HAVE A CARER?

Yes No

IF YES, PLEASE PROVIDE DETAILS

ARE YOU A CARER FOR SOMEONE ELSE?

Yes No

IF YES, PLEASE PROVIDE DETAILS

DO YOU HAVE A FAMILY HISTORY OF ANY OF THE PREVIOUS ILLNESSES? PLEASE INDICATE FAMILY MEMBER BELOW

Cancer

Stroke

High Blood Pressure

Heart Disease

FAMILY MEMBER

Smoking Status

DO YOU CURRENTLY SMOKE? *

Yes No

IF YES, HOW MANY PER DAY?

ARE YOU A PREVIOUS SMOKER? *

Yes No

IF YES, WHEN DID YOU QUIT?

IF YOU ARE A SMOKER AND WOULD LIKE TO STOP, WE WOULD ADVISE YOU TO TAKE UP THE OFFER OF A SMOKING CESSATION SERVICE BY CONTACTING ONE OF THE BELOW FOR SUPPORT

Telephone: 0800 122 3790

Text: STOPOXFORD to 60777

Website: www.stopforlifeoxon.org

NHS Advice: www.nhs.uk/smokefree

Repeat Medication

If you are on any repeat medication, please submit an Engage Consult to speak to a GP or Clinical Pharmacist within six weeks of registering.

We are unable to prescribe repeat medication without an initial consultation. Please have a list of current medication with you during your consultation.

ARE YOU ON ANY CURRENT PRESCRIBED MEDICATION?

Yes No

ARE YOU CURRENTLY TAKING OVER THE COUNTER ASPIRIN?

Yes No

Do you currently have or have you ever suffered with any of the following:

For Women Only

PLEASE PROVIDE THE DATE OF YOUR LAST CERVICAL SCREENING TEST

HAVE YOU EVER HAD A BREAST SCREENING TEST OR MAMMOGRAPHY?

Yes No

IF YES, PLEASE PROVIDE THE DATE OF YOUR LAST SCREENING

HAVE YOU HAD A HYSTERECTOMY?

Yes No

IF YES, WHEN WAS THIS DONE?

Summary Care Record and Oxfordshire Care Summary

All patients registered with a GP have a Summary Care Record (SCR), unless they have chosen not to have one. The information held in your Summary Care Record gives health and care professionals, away from your usual GP practice, access to information to provide you with safer care, reduce the risk of prescribing errors and improve your patient experience.

Your Summary Care Record contains basic information about allergies and medications and any reactions that you have had to medication in the past.

Summary Care Record - enables NHS Hospitals and Minor Injury Units across England access to your current medications, allergies and current health problems *

I do wish my information to be shared through the Summary Care Record

I do not wish my information to be shared through the Summary Care Record

Oxfordshire Care Record - enables hospitals and minor injury units across Oxfordshire access to your current medications, allergies, any bad reactions to medication and main current health problems *

I do wish my information to be shared through the Oxfordshire Care Record

I do not wish my information to be shared through the Oxfordshire Care Record

Patient Online Access Registration

Patient Access allows you to view your live electronic medical record online and request repeat prescriptions. In order to access your patient details online, you will need to bring photographic ID and proof of address in to the practice.

I would like to sign up to Patient Access and I fully understand that I need to bring the above mentioned ID into the practice to complete the Patient Access registration

Yes No

Patient Disclaimer

The information provided above is correct to the best of my knowledge.

I have read and understood the information enclosed in the Patient Information Pack and have indicated my consent preferences throughout this form.

SIGNATURE *

Signature of patient

Signature on behalf of patient

SIGNED (PLEASE PRINT FULL NAME) *

DATE *

RELATIONSHIP TO PATIENT

This form is protected by reCAPTCHA and the Google Privacy Policy and Terms of Service apply.

Cookies on the White Horse Medical Practice website

WHMP Adult Care Home Resident Registration Form

Further Information