Patient Registration

Personal Details

Title

Other Title

Family name

Forename

Date Of Birth

Address

Line 1

Line 2

Postcode

Town/City

Country

Address

Daytime Contact Telephone

Mobile Telephone Number

Previous Private Doctor

Current NHS Doctor / Practice

NHS Number

Please confirm if you consent to share your information with your NHS doctor when appropriate to have the best clinical practice

YES

Next of Kin

Next of Kin Details: (For emergency use only)

Full name

Relationship

Other Relationship

Contact number

Address

Line 1

Line 2

Postcode

Town/City

Country

Address

Consent to communicate by email

Please confirm that you do or do not give us your consent for us to communicate in this way

Yes, I consent to Palace Gate Practice communicating with me by email

NO, I do NOT consent to Palace Gate Practice communicating with me by email and I acknowledge that Reports & Test Results will be sent by post

Information Sharing

The General Medical Council (GMC) has advised that appropriate information sharing is an essential part of the provision of safe and effective care. Patients may be put at risk if those who provide their care do not have access to relevant, accurate and up to date information about them

YES, I consent to my medical information being shared with those involved with my treatment and care.

NO, I do NOT consent to my medical information being shared

Significant hospital stays

Please list any significant hospital stays:

Date

Reason

Operations and Procedures

Please list any operations or procedures:

Date

Procedure

Family Medical History

Please list any family history of medical problems (diabetes, stroke etc):

Relationship

Description

Allergies

Please list any allergies

Allergy

Current Medications

Please list all current medications

Medication name

Dosage

Do you smoke?

YES

Do you consume alcohol?

YES

How many units of alcohol do you consume per week?

Units

Please add any further information that you feel may be of relevance to us.

Additional Support

Do you have any cultural or religious beliefs that you would like to make us aware of prior to your appointment?

Do you have a physical or sensory impairment that may require adjustments to accommodate your visit? If Yes, please provide details on how we can accommodate you?

To comply with regulations implemented by the Care Quality Commission:

Would you like a chaperone to be present during physical examinations?

YES

Membership

To become a full member of the practice, you pay an annual membership fee. This entitles you to a range of benefits, including 24-hour care and home visits, and significantly discounted consultation fees. The advantages of membership are as follows:

Priority and same day appointments.
Reduced consultation fees.
Reduced telephone consultation fees.
Reduced health check-up fees.
Reduced charges for emails.
24-hour care.
Home visits (as long as you reside in our ‘home visit’ catchment area).
Free repeat prescriptions.
10% reduction on vaccine fees.
Free completion of passport application forms and personal health insurance claim forms.

Annual Membership Fee Adult: from £180/year
Children (16 & under) / students (up to the age of 21): No charge

Would you like to enrol in our Membership Scheme?

YES

Data Protection

Medical information will be kept confidential. It will only be disclosed to those involved with the provision of your treatment or care, or to their agents, and, if applicable, to any person or organization who may be responsible for meeting your treatment expenses, or their agents. Full details of our privacy / fair processing notice are available at reception or on the practice website - www.palacegatepractice.com.

Please help us keep our records accurate by informing us of any changes to your circumstances, address or other relevant information.

The Doctors and some of the Personnel at Palace Gate Practice involved in your care have access to your medical records to enable them to fulfill their functions. From time to time, information may be shared with others involved in your care. Everyone with access to your records is trained in confidentiality issues and is governed by both a legal and professional duty to keep your information private. All information about you is held securely and appropriate electronic safeguards are in place to help prevent accidental loss.

To protect your privacy, we will not disclose information over the telephone unless we are certain that we are talking to you. Information will not be disclosed to spouses, families or friends unless we have your prior written consent. We will not leave messages with others.

Patient's Name

Date

Patient’s Signature

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