New Patients - Tudor Lodge Health Centre

Title:

Please Specify

First Names: *

Surname: *

Prev Surname:

NHS Number:

Date of Birth: *

Ethnicity: *

First Spoken Language: *

Town and Country of Birth *

Address *

Address

City

County

Postcode

Telephone Number: *

Email Address: *

Mobile Number: *

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

Your previous address in the UK

Postcode

City

Country

Name of doctor while at that address

Address of previous doctor

Postcode

City

Country

Sex and Gender Identity

How would you describe your gender identity?

Please specify

Is your gender identity the same as the sex you were registered at birth?

Yes

No

This information helps us find your GP record.

What’s your sexual orientation?

Please specify

What are your preferred pronouns?

Please specify

Do you have a cervix?

Yes

No

Date of your last smear test if you are aged 25 or over (MM/YYYY – if known)

Where did you have your last smear test done?

What was the result of your last smear test?

Family History of Cancer

Does your family have a history of cancer?

Yes

No

Please specify which family member/s had which types of cancer

If “other” please specify what type of cancer and the family member that had it

If you are from abroad:

Your first address where registered with a GP

Postcode

City

Country

If previously resident in UK, date of leaving

Date you first came to live in the UK

If you are from the Armed Forces:

Have you ever served in the British Armed Forces?

Yes

No

Address before enlisting

Postcode

City

Country

Service or Personnel number

Enlistment date

Discharge date

If registering a child under 5:

I wish the child above to be registered with the doctor named overleaf for Child Health Surveillance.

If you need your doctor to dispense medicines and appliances * :

* Not all doctors are authorised to dispense medicines.

I live more than 1 mile in a straight line from the nearest chemist.

I would have serious difficulty in getting them from the chemist.

Would you like a blood test to screen for:

HIV

Hepatitis B

Hepatitis C

Emergency Contact

Name:

Relationship:

Contact Number:

Address:

Postcode

City

Country

I have filled in this form on behalf of

Online Registration Form

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

Sex and Gender Identity

Family History of Cancer

If you are from abroad:

If you are from the Armed Forces:

If registering a child under 5:

If you need your doctor to dispense medicines and appliances * :

Would you like a blood test to screen for:

Emergency Contact