New Patient Registration Form Step 1 of 14 7% Register with Broomfield Park Medical Centre It takes around 15 minutes to complete a registration. Please answer all the questions in full. Failure to complete this form correctly could result in your registration being rejected. Adults (16 plus) need to be able to provide proof of address and photo ID using the file link in this form For multiple or family registrations you need to complete one registration form per person. We aim to register you within 2 weeks of receiving your details and we will send you a confirmation text or email once you are registered on our system. Other ways to register If you are unable to register online, please come into our surgery as we can offer you paper forms. You will need to take this away and bring it back to reception completed in full and you will need to bring your proof of address and photo ID (for 16yrs plus). If you have registered with GP surgery in England before you will have an NHS number. Please have your NHS number ready when registering as this will help us find your medical records. You can find your NHS number on: Your NHS app Your NHS prescriptions papers Your NHS hospital letters Your NHS Baby Red Book Or by using this link Find your NHS number – NHS (www.nhs.uk) If there is an urgent medical emergency, please call 999. If it is less urgent but still important, please contact NHS 111 but calling the number 111. Practice BoundaryDo you live within our Practice Boundary? Please check prior to completing this form. Registrations are only accepted if you currently live within our permitted area. * Yes No Please Note If you do not live within our Practice Boundary, unfortunately, you will not be able to register at our practice. Please see NHS Choices for GPs in your area. Register with Broomfield Park Medical Centre It takes around 15 minutes to complete a registration. Please answer all the questions in full. Failure to complete this form correctly could result in your registration being rejected. Adults (16 plus) need to be able to provide proof of address and photo ID using the file link in this form For multiple or family registrations you need to complete one registration form per person. We aim to register you within 2 weeks of receiving your details and we will send you a confirmation text or email once you are registered on our system. Other ways to register If you are unable to register online, please come into our surgery as we can offer you paper forms. You will need to take this away and bring it back to reception completed in full and you will need to bring your proof of address and photo ID (for 16yrs plus). If you have registered with GP surgery in England before you will have an NHS number. Please have your NHS number ready when registering as this will help us find your medical records. You can find your NHS number on: Your NHS app Your NHS prescriptions papers Your NHS hospital letters Your NHS Baby Red Book Or by using this link Find your NHS number – NHS (www.nhs.uk) If there is an urgent medical emergency, please call 999. If it is less urgent but still important, please contact NHS 111 but calling the number 111. Let’s get your detailsWho are you registering for?Please select an option…MyselfChild 0-16Your titleMrMissMrsMsOtherPlease can you specify the other Your first name Your middle name (if applicable) Optional Your last name Your previous first or last names ? (if applicable) Optional What is your date of birth?Day12345678910111213141516171819202122232425262728293031Month123456789101112Year20262025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920What is your full home address? House name Number Locality Town Postcode Have you previously lived at another address in the UK?' Yes No Please provide your previous address below Have you ever registered with a GP in England? Yes No Please provide your previous GP practice details Which of the following best describes your gender?Please select an option…Identify as a femaleIdentify as maleNo binaryPrefers not to sayIs your gender the same as the sex you were assigned at birth? (this info helps us find your GP record) Yes No What is your sexual orientation? Sharing your sexual orientation allows us to provide you with personalised care. Please select an option…LesbianGayHeterosexualStraightAsexualBisexualQueerPolysexualPansexualWhat is your current relationship status?Please select an option…SingleMarriedDivorcedWidowedCivil partnerLives with partner Who is your emergency contact?Full Name Relationship to you Contact number Are they a registered patient at Broomfield Park? Yes No Do they live with you? Yes No Are they your carer? Yes No Are they your next of kin? Yes No If no, please state who is your next of kin Optional Do you give us consent to discuss your medical records with your next of kin in emergencies only? Yes No Upload DocumentsIn order for your registration to be accepted we require a copy of your photo ID. This can be a passport or drivers licence. Drop files here or Select files Max. file size: 1 GB. We also require a copy of your proof of address document. We accept a bank statement, utility bill, phone bill or tenancy agreement. This will need to be dated within the last 3 months and will not be accepted if outside of this time period. Drop files here or Select files Max. file size: 1 GB. This image is kept safe and is only accessed by our surgery staff with the sole purpose to register you. We will keep a copy of your Photo ID on our system, but we will destroy your proof of address confidentially once you are registered. Getting to know youDo you have an NHS number?Please select an option…YesNoWhat is your NHS number? This will be 10 numbers.What is your country of birth?Please select an option…AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland IslandsWhat is your ethnic groupPlease select an option…Asian or Asian BritishIndianPakistaniBangladeshiChineseAny other Asian backgroundBlack, Black British, Caribbean or AfricanCaribbeanAfricanAny other Black, Black British, or Caribbean backgroundMixed or multiple ethnic groupsWhite and Black CaribbeanWhite and Black AfricanWhite and AsianAny other Mixed or multiple ethnic backgroundWhiteEnglish, Welsh, Scottish, Northern Irish or BritishIrishGypsy or Irish TravellerRomaAny other White backgroundOther ethnic groupArabAny other ethnic groupWhat is your religion?Please select an option…African Traditional & DiasporicAgnosticAtheistBaha'iBuddhismCao DaiChinese traditional religionChristianityHinduismIslamJainismJucheJudaismNeo-PaganismNon-religiousRastafarianismSecularShintoSikhismSpiritismTenrikyoUnitarian-UniversalismZoroastrianismPrimal-indigenousWhere were you born?Please select an option…AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland IslandsWhen did you first come to live in England?(if you were born in the UK please skip this question) Day Optional Month Optional Year Optional Are you coming back from living abroad? Yes No When did you leave uk? Day Month Year When did you return? Day Optional Month Optional Year Optional Do you need an interpreter? Yes No If yes, please specify. Optional Do you have a copy of your vaccinations? Yes No Please provide the surgery with a copy of your vaccinations.Do you attend nursery/school/college or University? Yes No Please provide us with the name of your nursery/school/college or University Are you employed? Yes No Please specify your type of employment Optional What is your Housing statusPlease select an option…Own homeNursing homeRentedResidential accommodationOtherPlease specify Are you an asylum seeker? Yes No Date entry to uk Day Optional Month Optional Year Optional Do you have key code (please only share if you would like this to be added to your records) Optional Have you been registered with a UK Armed Forces GP before? You may be entitled to priority or specialised care if you or your family have served in the UK Armed Forces Yes No If yes, please specify Military Veteran Army veteran Royal air forces veteran Royal marine veteran Royal navy veteran Armed forces reservist Dependant of current serving member of British armed forces Family of active serving member of the armed forces, Member of the military family Family of active serving member of the armed forces reserves Dependant of former serving member of British armed forces Supplementary QuestionsWould you like to fill out the supplementary questions? These questions are optional and your answers will not affect your entitlement to register or receive services from your GP. Yes Optional No Optional These questions and the patient declaration are optional and your answers will not affect your entitlement to register or receive services from your GP. Anybody in England can register with a GP practice and receive free medical care from that practice. However, if you are not ‘ordinarily resident’ in the UK you may have to pay for NHS treatment outside of the GP practice. Being ordinarily resident broadly means living lawfully in the UK on a properly settled basis for the time being. In most cases, nationals of countries outside the European Economic Area must also have the status of ‘indefinite leave to remain’ in the UK. Some services, such as diagnostic tests of suspected infectious diseases and any treatment of those diseases are free of charge to all people, while some groups who are not ordinarily resident here are exempt from all treatment charges. More information on ordinary residence, exemptions and paying for NHS services can be found in the Visitor and Migrant patient leaflet, available from your GP practice. You may be asked to provide proof of entitlement in order to receive free NHS treatment outside of the GP practice, otherwise you may be charged for your treatment. Even if you have to pay for a service, you will always be provided with any immediately necessary or urgent treatment, regardless of advance payment. The information you give on this form will be used to assist in identifying your chargeable status, and may be shared, including with NHS secondary care organisations (e.g. hospitals) and NHS Digital, for the purposes of validation, invoicing and cost recovery. You may be contacted on behalf of the NHS to confirm any details you have provided. Please tick one of the following boxes: I understand that I may need to pay for NHS treatment outside of the GP practice I understand I have a valid exemption from paying for NHS treatment outside of the GP practice. This includes for example, an EHIC, or payment of the Immigration Health Charge (“the Surcharge”), when accompanied by a valid visa. I can provide documents to support this when requested I do not know my chargeable status I declare that the information I give on this form is correct and complete. I understand that if it is not correct, appropriate action may be taken against me. A parent/guardian should complete the form on behalf of a child under 16 SignedDate MM slash DD slash YYYY Print name Are you a carer? Yes No Carers look after someone who cannot look after themselves due to an illness, disability etc. carers can be adult or children, paid or unpaid. If you are a carer we may be able to offer you support. Who do you care for? Do you have any of the following long term conditions? Asthma COPD (Chronic Obstructive Pulmonary Disease) Diabetes Chronic Kidney Disease High blood pressure Heart disease / Heart failure Atrial Fibrillation Peripheral Arterial Disease Stroke Epilepsy Cancer Hypothyroidism / hyperthyroidism Osteoporosis Rheumatoid Arthritis Sickle Cell Mental health problems Depression Eating disorder Dementia Other None Do you have any allergies? Yes No Please list your allergiesIf your child is aged 0-5, do you have a copy of their vaccinations? Yes No Please bring your child’s red book into the surgery.Can you please obtain a copy of their vaccinations and bring a copy into the surgery’Are you on any current medications? Yes No Please specifyDo you consent for the electronic prescription service? Yes No CommunicationWhat is your Mobile Number? What is your email address? Would you like to include your work or home phone number? Yes No Please provide your work or home number below Do you consent to communication via text message? Yes No To you consent communication via email? Yes No Do you consent to communication via telephone? Yes No Do you have a preferred method of contact? Yes No I prefer… What is your main spoken language? Do you need an interpreter? Yes No Please specify the language Optional Do you have any communication needs? Yes No Please specify Optional Additional SupportDo you have a disability? Yes No Are you registered blind or partially sighted? Yes No Do you have a Hearing difficulty? Yes No Are you dependence on wheelchair? Yes No Do you have speech problems? Yes No Do you have any other disabilities Yes No If yes please specify. Optional Do you need any reasonable adjustments to make your visit to the GP Surgery accessible? Yes No If yes please specify. Do you give consent to share this reasonable adjustment with other organisations? Yes No Alcohol Do you drink alcohol? Yes No How often do you have a drink containing alcohol? Never (0) Monthly or less (1) 2/4 times/month (2) 2/3 times/week (3) 4+ times/week (4) How many units of alcohol do you drink on a typical day when you are drinking? 1-2 (0) 3-4 (1) 5-6 (2) 7-9 (3) 10+ (4) 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) almost daily or daily(4) AUDIT-C Score OptionalPlease answer the following questionsHow often during the last year have you found that you were not able to stop drinking once you had started? Never (0) Less than monthly (1) Monthly (2) Weekly (3) Daily or almost daily (4) How often during the last year have you failed to do what was normally expected from you because of your drinking? Never (0) Less than monthly (1) Monthly (2) Weekly (3) Daily or almost daily (4) How often during the last year have you needed an alcoholic drink in the morning to get yourself going after a heavy drinking session? Never (0) Less than monthly (1) Monthly (2) Weekly (3) Daily or almost daily (4) How often during the last year have you had a feeling of gut or remorse after drinking? Never (0) Less than monthly (1) Monthly (2) Weekly (3) Daily or almost daily (4) How often during the last year have you been unable to remember what happened the night before because you had been drinking? Never (0) Less than monthly (1) Monthly (2) Weekly (3) Daily or almost daily (4) Have you or somebody else been injured as a result of you drinking? Never (0) Yes, but not in the last year (2) Yes, during the last year (4) Has a relative or friend, doctor or other health worker been concerned about your drinking or sugged that you cut down? Never (0) Yes, but not in the last year (2) Yes, during the last year (4) AUDIT Score total Optional SmokingWhat is your smoking status? Current smoker Ex smoker Never smoked tobacco Cigarette smoker Pipe smoker Rolls own cigarettes Cigar smoker Vape user How many per day? Would you like free smoking advice and support? Yes No Physical activityWhat is your physical activity at WorkPlease select an option…not in employmentspends most of the time sittingspends most of time standing or walkingwork involves definite physical effortWork involves vigorous physical activityHow much Exercise do you participate in per week?Please select an option…nonesome but less than 1hbetween 1-3hours3h or moreHow much cycling do you do per week?Please select an option…nonesome but less than 1hbetween 1-3hours3h or moreHow much walking do you do per week?Please select an option…nonesome but less than 1hbetween 1-3hours3h or moreHow many hours do you take on House work/child care per week?Please select an option…nonesome but less than 1hbetween 1-3hours3h or moreHow many hours do you do Gardening/diy per week?Please select an option…nonesome but less than 1hbetween 1-3hours3h or moreWhat is your walking pace?Please select an option…slowsteadybriskfastnonesome but less than 1hbetween 1-3hours3h or moreWhat is your weight?please use kgWhat is your height?please use cm ConsentWould you like to share a summary of your GP care Record (SCR) with authorised care professionals? For example, NHS 111, 999, accident & emergency etc. Yes – for medication, allergies, adverse reactions, and any additional information in my medical records. No – I do not permit access to my summary care record. Further informationPlease choose your nominated pharmacy that you would like your medications to be sent to.Would you like to take part in our patient participation group? Yes No Would you like a free HIV test? Yes No Please visit: https://www.coventry.gov.uk/health-wellbeing/hiv/2 Consent I declare that all the information I have provided on this online form is true and to the best of my knowledge.SignatureFull Name Date Day Month Year FeedbackHow did you find our registration process? exceptional very good satisfied not satisfied Is there anything we could improve on?If you have any questions please contact cwicb.bpmconlineregistrations@nhs.net .