New Patient Questionnaire These questions help your new GP get to know you and your medical problems. Please return this form to the surgery as soon as possible or bring it when you first visit the doctor or nurse. Your registration may be delayed if you have not completed this form in full. Surname: First Name (S): Mr/Master/Mrs/Miss/Ms/Dr/Other Previous Surname: Address (including postcode) Date of Birth: / / Home Tel No: … … … … … … … … Mobile Tel No: Work Tel No: Email Address: Marital Status: Occupation: Can the practice use your mobile number to text you Date Form Completed: appointment reminders etc  Yes  No We use a software program to send text messages for appointment reminders, health campaigns, and messages. If you give us your mobile number and do not indicate that you do not wish for it to be used for these purposes then we will use it to ensure we can provide the best possible care. You can inform us at any point that you do not wish us to text you. You must inform the surgery if you change address, or if any of your contact telephone numbers change. Please indicate your ethnic origin:- English Irish Scottish □ □ □ Welsh Other White Background Pakistani or British □ □ □ Pakistani Bangladeshi or British Other Asian or Asian Black British □ □ □ Bangladeshi Unspecified Other Black Background Chinese White and Black Caribbean □ □ □ Caribbean White and Asian Indian or British Indian □ □ □ Other □ Do you currently have a nominated pharmacy for your prescriptions? All your prescriptions will continue to be sent there unless you inform us that you wish to change your nomination. If you live more than a mile (as the crow flies) from a pharmacy we can dispense to you. Current Nominated Pharmacy New Nominated Pharmacy Dispensing? (only if living more than a mile from a chemist) Please list the names and dates of birth of any other householder, including children, who live at the address you have provided above. Name DOB Relationship to You
New Patient Questionnaire These questions help your new GP get to know you and your medical problems. Please return this form to the surgery as soon as possible or bring it when you first visit the doctor or nurse. Your registration may be delayed if you have not completed this form in full. Surname: First Name (S): Mr/Master/Mrs/Miss/Ms/Dr/Other Previous Surname: Address (including postcode) Date of Birth: … … / … … / … … … … Home Tel No: Mobile Tel No: Work Tel No: Email Address: Marital Status: Occupation: Can the practice use your mobile number to text you appointment reminders etc  Yes  No Date Form Completed: We use a software program to send text messages for appointment reminders, health campaigns, and messages. If you give us your mobile number and do not indicate that you do not wish for it to be used for these purposes then we will use it to ensure we can provide the best possible care. You can inform us at any point that you do not wish us to text you. You must inform the surgery if you change address, or if any of your contact telephone numbers change. Please indicate your ethnic origin:- □ English □ Irish □ Scottish □ Welsh □ Other White Background □ Pakistani or British Pakistani □ Bangladeshi or British Bangladeshi □ Other Asian or Asian Unspecified □ Black British □ Other Black Background □ Chinese □ White and Black Caribbean □ Caribbean □ White and Asian □ Indian or British Indian □ Other Do you currently have a nominated pharmacy for your prescriptions? All your prescriptions will continue to be sent there unless you inform us that you wish to change your nomination. If you live more than a mile (as the crow flies) from a pharmacy we can dispense to you. Current Nominated Pharmacy New Nominated Pharmacy Dispensing? (only if living more than a mile from a chemist) Please list the names and dates of birth of any other householder, including children, who live at the address you have provided above. Name DOB Relationship to You