Gender *


 
First Name *

 
Middle name(s)

 
Surname *

 
Previous Surname

 
NHS Number

 
Date of Birth *

 
Place and Country of Birth *

 
Current Home Address *

You must be Lambeth resident to be registered with The Exchange Surgery
 
Post Code *

 
Main telephone number *

 
Other contact number

 
Previous Home Address *

Help us to trace your previous medical records by providing us with this information
 
Have you been registered with a GP in UK before? *


 
To help us to trace your previous medical records please provide us with name of your previous doctor and address of the surgery

 
If you are from abroad, when did you first came to the UK?

If you don't remember exact date, please estimate it
 
Is anyone from your household already registered at this practice? Please provide their names and date of birth:

 
Do you have any chronic illness?


 
Do you take regular medication for any conditions? Please state name of medication, dose and when will run out

 
The ELECTRONIC PRESCRIPTION SERVICE (EPS) is a NHS Service. It gives you the chance to change how your GP sends your prescription to the place you choose to get your medicines or appliances from. Your prescription will be sent electronically to the pharmacy of your choice. This means you will not need to come into the surgery to collect your prescription as it will be prepared and ready for collection at your chosen pharmacy.

 
Name and address of your chosen pharmacy

 
If you have a chronic condition or are on any regular medication then you need to book an appointment with the nurse for BEFORE you run out of your medication. Many chronic conditions need monitoring – annually if not more frequently.

 
Have any close relatives (father, mother, sister, brother ONLY) ever suffered from any of the following:


 
Have you had any of these immunisations


 
Do you have any allergies? Please state

 
All patients can have a sexual health screen with a Practice Nurse including HIV test. Please indicate here if you wish to have this and reception will book one. Would you like to be booked with a nurse?

     
 
What is your height

 
What is you weight

 
Smoking status

 
Do you smoke *

     
 
Are you ex-smoker?

     
 
How many cigarettes do you smoke daily?

 
We can support you in quitting smoking.  Would you like help to quit smoking?

     
 
Do you drink alcohol? *

     
 
If you drink alcohol, please answer following questions.

Your answers will be scored. Score of 5+ indicated increasing or higher risk drinking, therefore we will contact you to offer support.
 
How often do you have a drink containing alcohol?


 
How many units of alcohol do you drink on a typical day when you are drinking?

One unit of alcohol is:
- half pint of regular beer, larger or cider
- 1 small glass of wine
- 1 single measure of spirits

 
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?


 
For female patients only

 
Are you currently, or think you may be pregnant?

     
 
Which method of contraception (if any) are you using at present?

 
Have you had a cervical smear test?

     
 
If yes, what was the result?

 
If you had cervical test, what was the date?

 
What is your ethnicity? *


 
What is your religion?

 
What is your main spoken language?

 
Do you require an interpreter? If yes, state language

 
Next of kin details

Please provide name and contact telephone number
 
There is a Central NHS Computer System called the Summary Care Record (SCR). It is an electronic record which contains information about the medicines you take, allergies you suffer from and any bad reactions to medicines you have had. Storing information in one place makes it easier for healthcare staff to treat you in an emergency, or when your GP practice is closed.This information could make a difference to how a doctor decides to care for you, for example which medicines they choose to prescribe for you. You can find out more on www.nhscarerecords.nhs.uk

 
Summary care records - Would you like to


 
Sharing with other services We may need to share your medical information with other organisations involved in the delivery of your care e.g. Podiatry or District Nursing. We will not share identifiable information with anyone that isn’t involved in your care unless legally required to.   To maintain continuity of clinical care, we upload certain medical information so that it is available to other healthcare organisations (eg Emergency Departments).  Please see our website or ask receptionist for a leaflet which details what part of your record is extracted and how it is used to help other NHS organisations.    If you wish to Opt out, please speak to receptionist.

 
Do you want to be allocated to any specific doctor? New patients are currently being assigned to one of our partners as the usual named doctor. You can change your usual doctor if you wish at any time, by asking at reception or e-mailing us.

 
You can now book appointments online, order repeat prescriptions, message the doctor and access most of your medical records online using www.patient-access.co.uk.
If would like the access, you need to bring your photo ID and proof of address and fill out an application form. The receptionist will issue login details once we confirm your registration.

 
Would you like to have on-line access?

     
 
Where you have provided information on how to contact you, can you confirm you are happy for The Exchange Surgery to contact you by the following:

 
By text ( for appointments reminders and test results)

     
 
BY email (for example to send you letters, newsletters and password reminders)

     
 
Signature *

Please write your name or parent/carer for under 16s
 
Date completed *

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