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.	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. 

4.	Please list the town, county and country of your place of birth? 
            ____________________________________________________________________________

5.	Do you require interpreter services for your appointments? 
 YES   or      NO

6.	Are all childhood vaccinations up to date? Please submit a print out from your previous practice of current vaccination list. 
                                            YES    or    NO

7.	Please ensure that you have informed your current Health Visitor that you are changing GP practice and notify Hillsborough Community Services by telephoning 02892683609. 

8.	Next of Kin Information

ALTERNATIVE EMERGENCY CONTACT DETAILS
Full name:_____________________________
Relationship to patient:__________________
Daytime phone number _________________
Mobile phone number:__________________

PARENT/GUARDIAN CONTACT DETAILS
Full name:_____________________________
Relationship to patient:__________________
Daytime phone number _________________
Mobile phone number:__________________

 

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

If YES, please state details below
_____________________________________________

9.	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 

10.	Permission

FAMILY HISTORY
Please tick and write which family member 

Family Member(s)

Illness

High BP

Stroke

Diabetes

Cancer

Heart Disease

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

For us to enter your ECR records so we can obtain your medication list from your previous practice?____________

11.	Health Promotion 

•	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.