Concord Medical Centre

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Online new patient registration form

This is for new patients only.

Simply complete and submit the form below and you will be registered with the surgery and able to book an appointment. When you attend for your first appointment please bring two forms of ID with you so that we can confirm your details for the NHS registration process.

Title*

Gender*

Ethnicity*

What is your date of birth?*
For example, 15 3 1984

Where were you born?

Names

Contact Information

What is your address?*

Please help us trace your previous medical records by providing the following information

Your NHS number is a 10 digit number that you can find on any letter the NHS has sent you. For example, 458 777 3456. By providing your NHS number it helps us to ensure safely matching your records from the NHS spine.

Do you have a previous address in the UK?*

What is your previous address in the UK?*

Have you previously been registered at another GP surgery?*

What is the name and address of your previous GP?*

Were you born abroad?*

What is your first address in the UK?*

Date you first came to live in the UK?*

For example, 15 3 1984

If you were previously a resident in UK, please provide the date you left?

For example, 15 3 1984

Are you returning from the armed forces?*

What was your address before enlisting?*

What day did you enlist?*
For example, 15 3 1984

New Patient Questionnaire

  • This practice creates summary care records (SCR). A SCR is an electronic record of your current medication and any allergies you may have. This record will be available to other services such as out of hour’s services, 111, A&E etc. to help if you need emergency treatment.
  • If you have any outstanding hospital appointments please contact the hospital and advise them that you have changed your doctor, name and address (if applicable).
  • If you are a carer (i.e. you provide care for someone who is physically or mentally impaired) please ask at reception for a Carers Pack, which contains information that may help you.

Please indicate whether you wish to opt in or out*

Are you cared for?*

Carers details*

Is the carer registered with this Practice?*

Next of kin details

Title*

Are they also a patient of Concord Medical Practice?*

Do they live at the same address as you?*

Details About You

Are you aged over 16?*

Height and weight*

Smoking status*
Do you want to quit smoking? Please visit https://www.nhs.uk/smokefree for more information or contact the surgery.

What is your alcohol consumption?*

How many standard drinks containing alcohol do you have on a typical day?*

How often do you have six or more drinks on one occasion?*

Patient Access Registration

With Patient Access standard access -

All patients have access to:

  • Booking appointments
  • Requesting repeat prescriptions
  • Demographics – change of contact details
  • Viewing my allergies
  • Viewing my medication

Additional Access under standard access:

  • Booking appointments

Would you like to register for Patient Access?*

Detailed Coded Access -

Patients who select additional access have access to all actions listed under standard access, as well as:

  • Patient medical problems
  • Viewing consultations
  • Viewing medical documents
  • Viewing test results

Detailed Coded Access -

Patients who select additional access have access to all actions listed under standard access, as well as:

  • Patient medical problems
  • Viewing consultations
  • Viewing medical documents
  • Viewing test results

Detailed Coded Access - Please tick if required*

Detailed Coded Access - Please tick if required*

By registering for Patient Access

I wish to access my medical record online and understand and agree with each statement:

  • I will be responsible for the security of the information that I see or download.
  • If I choose to share my information with anyone else, this is my own risk.
  • I will contact the practice as soon as possible if I suspect that my account has been accessed by someone without my agreement.
  • If I see information in the record that is not about me, or is inaccurate, I will contact the practice as soon as possible. I will treat any information not about me as confidential.
  • I have read and understood the information leaflet provided by the practice.

By registering for Patient Access

I wish to access my medical record online and understand and agree with each statement:

  • I will be responsible for the security of the information that I see or download.
  • If I choose to share my information with anyone else, this is my own risk.
  • I will contact the practice as soon as possible if I suspect that my account has been accessed by someone without my agreement.
  • If I see information in the record that is not about me, or is inaccurate, I will contact the practice as soon as possible. I will treat any information not about me as confidential.
  • I have read and understood the information leaflet provided by the practice.

How would like to receive your login details for Patient Access?*

How would like to receive your login details for Patient Access?*

Please confirm your email address?*

Please also opt IN to receive emails if you have said you would like to receive your Patient Access details via email.

Please confirm your email address?*

Please also opt IN to receive emails if you have said you would like to receive your Patient Access details via email.

New Patient Questionnaire

We would like to contact you via SMS text messaging and via email. Please opt in or out of each service below.

We may wish to send SMS messages to our patients for reasons that include, but are not limited to, test results, appointment reminders, COVID-19 appointment invite, treatment information and to inform you that your registration is complete.

We may wish to send emails to our patients for reasons that include, but are not limited to, test results, appointment reminders, treatment information, information regarding your online registration and your Patient Access registration details.

We would like to contact you via SMS text messaging. Please opt in or out of the service below.*

We would like to contact you via email. Please opt in or out of the service below.*

Medication

Are you allergic to any medicine, tablets or other substances?*

Do not include personal or financial information, for example, your National Insurance number or credit card details.

Current Medication:

If you are on regular medication please attach your repeat prescription tear off slip to this questionnaire if available.

We operate an Electronic Prescribing Service (EPS), which means that your repeat prescription will go electronically to your nominated pharmacy otherwise you will have to collect your paper prescription from reception. Please nominate a pharmacy of your choice below:

  • Please indicate ONE pharmacy you would like to use by ticking the appropriate box below
  • You may be asked to see a doctor to organise your first repeat prescriptions but subsequent requests will be sent direct to the pharmacy you choose
  • You will need to collect your medication from your chosen pharmacy every time you order a repeat prescription (any changes must be notified in writing)
  • PLEASE ALLOW 72 HOURS BETWEEN THE TIME YOU ORDER AND THE TIME YOU COLLECT FROM YOUR CHOSEN PHARMACY

Please choose you preferred pharmacy*

Please choose where appropriate how you heard about us?

Please supply proof of address.

No files selected!

Please supply proof of identity.

No files selected!

We require proof of identity such a photo of your passport or driving licence and proof of address such as a photo of a utility bill or bank statement.