APPLICATION FORM TO JOIN HILLSBOROUGH MEDICAL PRACTICE

Full names of applicant	Date of birth	Address	

		

Postcode:___________________________
Mobile Number:____________________
Home Number:_____________________
Email:_______________________________

1.	Tick to opt in to receiving correspondence from us via: 
Email				Text Messaging

1.	Have you had a previous surname(s)?________________________________________________

2.	Please list your previous address: ____________________________________________________ __________________________________________________________________________________________

We really appreciate you taking the time to complete ALL the questions asked in order for us to complete your registration process as smoothly and efficiently as possible.
If we require further information which has not been disclosed to us during the registration process this can delay your application.
Please submit a copy of your current medication list from your current practice along with your application. 
Please allow 5 working days for your application to be processed.
1.	What practice & GP are you currently registered with? _________________________________________________________________________________

2.	How long have you been registered with this practice?   _________________________________________________________________________________
Are you registered at this practice as: (Please tick)
                       A Temporary Resident                           A Permanent Resident
•	If you are a Temporary Resident where was the last practice that you held permanent status? ___________________________________________________________

3.	What is your current occupation? ________________________________________________________________________________

4.	Have you been living outside the UK in the past 5 years?    
 YES     or     NO 

•	If YES, please ensure you have been fully registered at your current practice and not registered temporarily. 

5.	Please list the town, county and country of your place of birth? 
            ____________________________________________________________________________
6.	Do you require interpreter services for your appointments? 
 YES   or      NO
	If YES, which language do you require your interpreter in?
	____________________________________________________________

7.	
FAMILY HISTORY
Please tick and write which family member 

Family information

NEXT OF KIN/EMERGENCY CONTACT DETAILS
Full name:_____________________________
Relationship to patient:__________________
Daytime phone number _________________
Mobile phone number:__________________

Family Member(s)

Illness

High BP

Stroke

Diabetes

Do you give your next of kin permission to

Cancer

        discuss your record?         
 		  YES         NO

Heart Disease

Are you a carer for any family member(s)? 
YES    NO 

      If YES, please state details below
_____________________________________________

8.	Medical History

MEDICATION
Please list any medication that you are currently taking: 

SIGNIFICANT MEDICAL HISTORY
Please list any significant medical history below: 

NON - DRUG ALLERGIES
Please list any  NON - drug allergies 

DRUG ALLERGIES
Please list any drug allergies 

9.	Permission

Do you give permission for: (Please tick)
•	Your records to be shared with Out of Hour hospital services? _________

Are you on the NHS donor register list? ________
•	At any stage if you join the donor register list please inform the practice

Do you give us permission to access your ECR record to obtain your medication list from your previous practice? __________

10.	Health Promotion 

Smoking Habits (Please tick)
       I have never smoked 
        I am an ex-cigarette smoker and stopped         
        in ____. I  previously smoked ___ per day 

        I smoke ____ cigarettes per day 

        I smoke a pipe or cigars

        I smoke an e-cigarette

        I am an ex e-cigarette smoker      

Alcohol Intake
How many units would you drink per week? ________________
(A unit is ½ pint of beer, a small glass of wine, an alcopop. A pub measure of spirit is 1 ½ and a can of extra strong lager is 4 ½ units)

•	What is your weight? ____________KG

•	What is your height? ____________CM

Many thanks for your cooperation in filling out our application forms. Please allow 5 working days for your application to be processed.