For Office Use Only Form checked and fully completed? Yes No Opt Out form completed? Yes No Ethnicity form completed? Yes No Online access requested? Yes No Online access form given GP Patient informed. Yes No Coded on EMIS ………………… Smoking cessation appointment required? Yes No Appointment booked Details: ……………………… BBV test required? Yes No Test forms will be posted to patient by GV. Chlamydia self-testing kit Yes No N/A New Patient healthcheck appointment required Yes No Appointment booked Details: ……………………… Alcohol advisor appointment required? Yes No Appointment booked Details: ……………………… Practice leaflet given? Yes No Receptionist’s Name and Initials ………………………………………….. Place of birth recorded (including London Borough)…………………………………….. Date Registered……………………………………………………………………………… NHS 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 options that apply. Any of my organs and tissue or Kidneys Heart Liver Corneas Lungs Pancreas
For Office Use Only Form checked and fully completed? Opt Out form completed? Ethnicity form completed? Online access requested? GP ………………… Patient informed. Smoking cessation appointment required? BBV test required? Chlamydia self-testing kit New Patient healthcheck appointment required Alcohol advisor appointment required? Practice leaflet given? Receptionist’s Name and Initials Yes No Yes No Yes No Yes No Online access form given Yes No Coded on EMIS Yes No Appointment booked Details: ……………………… Yes No Test forms will be posted to patient by GV. Yes No N/A Yes No Appointment booked Details: ……………………… Yes No Appointment booked Details: ……………………… Yes No ………………………………………….. Place of birth recorded (including London Borough)…………………………………….. Date Registered……………………………………………………………………………… NHS 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 options that apply. Any of my organs and tissue or Kidneys Heart Liver Corneas Lungs Pancreas
New%20Patient%20HGP%20Adult%20LP%20registration%20form.docx