New patient registration – Washingborough Family Practice

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Family doctor services registration (GMS1)
Patient's details

Mr Mrs Miss Ms
First names
Surname
Previous surname/s
Date of birth

Day Month Year
NHS Number
Gender

Male Female
Town and country of birth
Address

Street Address

Street Address Line 2

City County

Postcode
Telephone Number
Please help us trace your previous medical records by providing the following information.
Address

Street Address

Street Address Line 2

City County

Postcode
Name of previous GP practice while at the address
Address of previous GP practice
If you are from abroad
Your first UK address where registered with a GP

Street Address

Street Address Line 2

City County

Postcode
If previously resident in UK, date of leaving

Day Month Year
Date
Date you first came to live in UK

Month Day Year
Were you ever registered with an Armed Forces GP
Please indicate if you have served in the UK Armed Forces and/or been registered with a Ministry of Defence GP in the UK or overseas.

UK or overseas Regular Veteran Family Member (Spouse, Civil Partner, Service Child)
Address

Street Address

Street Address Line 2

City County

Postcode
Service or Personnel number
Enlistment date

Day Month Year
Discharge date

Day Month Year
Footnote: These questions are optional and your answers will not affect your entitlement to register or receive services from the NHS but may improve access to some NHS priority and service charities services.
If you need your doctor to dispense medicines and appliances

I live more than 1.6km in a straight line from the nearest chemist I would have serious difficulty in getting them from a chemist
Signature of Patient

Clear
Signature on behalf of Patient

Clear
Date

Day Month Year
Date
NHS Organ Donor registration
I want to register my details on the NHS Organ Donor Register as someone whose organs/tissue may be used for transplantation after my death. Please tick the boxes that apply.

Any of my organs and tissue or Kidneys Heart Liver Corneas Lungs Pancreas
Date

Day Month Year
Signature confirming my consent to join the NHS Organ Donor Register

Clear
Please tell your family you want to be an organ donor. If you do not want to be an organ donor, please visit www.organdonation.nhs.ul or call 0300 123 23 23 to register your decision.
NHS Blood Donor registration
I would like to join the NHS Blood Donor Register as someone who may be contacted and would be prepared to donate blood.

Tick here if you have given blood in the last 3 years
Date

Month Day Year
Date
Signature confirming my consent to join the NHS Blood Donor Register

Clear
Address

Street Address

Street Address Line 2

City County

Postcode
NEW PATIENT HEALTH QUESTIONNAIRE
Welcome to Washingborough Family Practice. It is in the interest of both yourself and your doctor that you fill this questionaire to the best of your knowledge.
Name

First Name Last Name
Date of birth

Day Month Year
Address

Street Address

Street Address Line 2

City County

Postcode
Telephone number
Home Tel
Mobile Tel
Work Tel
Email
example@example.com
Occupation
Religion
First Language
Next of kin name

First Name Last Name
Ethnic origin
Have you ever been in the forces?

Yes No
From

Day Month Year
To

Day Month Year
Date
Rank
Service Number
National Service Number
Are you a carer?

Yes No
Women Only
If any, what contraception do you use?
Date

Day Month Year
Have you had a Hysterectomy?

Yes No
Are you currently pregnant

Yes No
Family History – Is there any history of the following in your immediate family

Heart attack Heart disease Angina Glaucoma Cystic fibrosis Epilepsy Diabetes Depression High blood pressure Bowel Cancer Breast cancer Stroke
Other, please specify
New Patient Signature

Clear
Signature Date

Day Month Year
Please tick if you suffer from or have ever had any of the following conditions

Asthma High Blood Pressure Angina Bowel Trouble Epilepsy Diabetes Stroke Gynae Problems Glaucoma Heart Trouble Hayfever Thyroid Disease Pneumonia/Bronchitis Bladder/Kidney disease Arthritis/Joint Problems Depression/Anxiety Cataracts Any cancers
Do you have any other health problems or health risk that the doctor/Nurse should be aware of?
Are you on any repeat medication? If yes then please enclose a copy of your last repeat prescription slip.this will help us in providing a continual supply of medication. Please be aware we are not informed of your medication needs from your previous GP

Cancel of
Please state any know allergies
Reaction
Smoking Status

I have never smoked I used to smoke but i do not smoke now I do smoke How many cigarettes per day?
How often do you have a drink that contains alcohol?

Never Monthly or Less 2-4 times per month 2-3 times per week 4+ times per week
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 Less than monthly Monthly Weekly Daily or almost daily
How often during the last year have you found that you were not able to stop drinking once you had started?

Never Less than monthly Monthly Weekly Daily or almost daily
How often during the last year have you failed to do what was normally expected from you because of your drinking??

Never Less than monthly Monthly Weekly Daily or almost daily
How often during the last year have youn eeded an alcoholic drink in the morning to get yourself going after a heavy drinking session?

Never Less than monthly Monthly Weekly Daily or almost daily
How often during the last year have you had a feeling of guilt or remorse after drinking?

Never Less than monthly Monthly Weekly Daily or almost daily
How often during the last year have you been unable to remember what happened the night before because you had been drinking?

Never Less than monthly Monthly Weekly Daily or almost daily
How often during the last year have you been unable to remember what happened the night before because you had been drinking?

No Yes, but not in the last year Yes, during the last year
Has a relative or friend, doctor or other health worker been concerned about your drinking or suggested that you cut down?

No Yes, but not in the last year Yes, during the last year
Are you currently under Hospital Care

Yes No
Please give details
Do you consider yourself to have a disability?

Yes No
Details of impairment

Physical Impairment Sensory Impairment Learning Disability/Difficulty Mental Health Condition Other
If other please state
SMS Messaging

This is to confirm that I give consent for the Surgery to send text messages to my mobile phone. These textswill be to remind me of future appointments and for health matters relating to my treatment.I am aware that if I change my mobile phone number, it is my responsibility to inform the surgery.
Signature for SMS messaging conesent

Clear
Your Nominated Pharmacy

We can send your prescriptions electronically to a Pharmacy of your choice, please let us know your preferredPharmacy to enable us to do this.
Patient Record Sharing Preferences Consent Form
Please make sure you read the enclosed information sheet for patients prior to signing this form.
I confirm I have read the patient’s guide entitled “ Your electronic patient record and the sharing of information

Yes No
Name

First Name Last Name
Date of birth

Day Month Year
Address

Street Address

Street Address Line 2

City County

Postcode
ENHANCED DATA SHARING MODEL (eDSM) – SHARING OUT

Sharing out means that any information that we have recorded at our practice (all consultations, results, medication etc.) will be available for other NHS organisations to see if you allow them to. (You will be asked for your consent for this) . This will make all information added at Washingborough Surgery sharable, and we will be unable to keep any of your information confidential to the surgery.

You can always change your mind, but if you have chosen to share information with other NHS organisations and then decide against it we cannot retrieve any information already shared.

If I choose to make any information from Washingborough Surgery shareable, I understand this means that ALL information recorded at Washingborough Surgery will be available for other NHS services to view.
I do/do not wish to make my information from Washingborough Surgery sharable to other healthcare organisations.

I do I do not
Signature

Clear
Date of signature

Day Month Year
Date
ENHANCED DATA SHARING MODEL (eDSM) – SHARING IN

Sharing in means that Washingborough Surgery will be able to see all information added by other healthcare organisations. This will only happen if you have consented to share information out at the other organisations.

I do/do not wish to allow Washingborough Surgery to view information added at other healthcare organisations.
I do/do not wish to allow Washingborough Surgery to view information added at other healthcare organisations.

I do I do not
Signature

Clear
Date of signature

Day Month Year
Should be Empty:

General Information

South Lincoln PCN /
PCN-UN93726
01522 303600

Our Address

School Lane, Washingborough
Lincoln, LN4 1BN
Contact | Careers

Opening Times

LN4 1BN - 8.00am-6.30pm
LN4 1NZ - 8.30pm - 12.30pm
Weekends - Closed

Latest News

IMPORTANT ANNOUNCEMENT

September 1, 2021/

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Family doctor services registration (GMS1)

NEW PATIENT HEALTH QUESTIONNAIRE

Patient Record Sharing Preferences Consent Form