New patient registration – Radcliffe Medical Practice

Patient's details

Please be aware it can take up to 2 weeks for your registration to be processed. If you need urgent medical care, please contact your current GP surgery or 111. If you take repeat medication, please order from your current surgery to cover the transition period

Title*

Mr
Mrs
Miss
Ms

First names*

Surname*

Date of birth*

NHS Number*

Previous surnames

Gender*

Male
Female

Town and country of birth*

Home address*

Postcode*

Telephone number*

Email

Notification Preferences

Please let us know whether you consent to receive notifications from the practice via SMS or email.

Consent to receive SMS
Consent to receive Email

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

Your previous address in UK

Name of previous GP practice while at that address*

Address of previous GP practice while at that address

Name of your previous GP whilst at this practice*

If you are from abroad

Your first UK address where registered with a GP

If previously resident in UK, date of leaving

Date you first came to live in the United Kingdom

Were you ever registered with an Armed Forces GP

Please indicate if you have served in the UK Armed Forces and/or been registered with a Ministry of Defence GP in the UK or overseas

Regular
Reservist
Veteran
Family Member (Spouse, Civil Partner, Service Child)

Address before enlisting

Service or Personnel number

Postcode

Enlistment date

Discharge date (if applicable)

Footnote: These questions are optional and your answers will not affect your entitlement to register or receive services from the NHS but may improve access to some NHS priority and service charities services.

If you need your doctor to dispense medicines and appliances*

I live more than 1.6km in a straight line from the nearest chemist
I would have serious difficulty in getting them from a chemist

*Not all doctors are authorised to dispense medicines

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 boxes that apply.

Please tell your family you want to be an organ donor. If you do not want to be an organ donor, please visit www.organdonation.nhs.uk or call 0300 123 23 23 to register your decision.

NHS Blood Donor registration

Yes I would like to join the NHS Blood Donor Register
Tick here if you have given blood in the last 3 years

I would like to join the NHS Blood Donor Register as someone who may be contacted and would be prepared to donate blood.

My preferred address for donation is: (only if different from above, e.g. your place of work)

All blood types are needed, especially O negative and B negative. Visit www.blood.co.uk or call 0300 123 23 23.

Personal Details

Sexual Orientation

Smoking Status

Smoker
Never Smoked
Ex-Smoker

Ethnic Origin

Asian or Asian British

Bangladeshi
Indian
Pakistani
Any Other Asian Background

Ethnicity

White

Ethinicity

Mixed

Black and White Caribbean
Black and White African
Asian and White
Any Other Mixed Background

Ethnicity

Chinese or Other ethnic Group

Chinese
Other Ethnic Group

Ethnicity

Black or Black British

African
Caribbean
Any Other Black Background

Do you require an Interpreter? If so, please state the language below

Children Registration Parental Authority Declaration Form

Please give names and contact number of all people who have legal parental responsibility for the child. (Usually the child's biological/adoptive parents)

Drug Dependence Policy - New Patients

Drugs of Dependence Policy - New Patients A controlled substance is generally a drug or chemical whose manufacture, possession, or use is regulated by the government because of the potential for abuse or addiction. Such drugs include those classified as narcotics, stimulants, depressants, hallucinogens, and cannabis. A list of the most commonly encountered controlled drugs: Morphine, Pregabalin, Oxycodone, Gabapentin, Fentanyl, Temazepam, Buprenorphine, Nitrazepam, Codeine, Diazepam, Dihydrocodeine, Lorazepam, Tramadol, Zopiclone, Tapentadol, Zolpidem. New Patients: Please inform staff if you are prescribed any of the above medication. Some of our patients require strong, potentially addictive medication to help manage their condition(s). Of concern are ‘drugs of dependence’ (e.g. opioid medications and benzodiazepines), particularly when these are prescribed on an on-going basis. Due to increasing reports of abuse of prescription drugs Waterfoot Medical Practice has established a policy to ensure adequate treatment of your condition, while reducing the risk of problems with drug prescriptions. If you are a new patient to the practice: • It may take time to get accurate medical information about your condition. Until such information is available, your GP may choose not to prescribe any medication. It is our policy that GPs do not prescribe drugs of dependence until they have a full clinical picture. • Your GP may decide not to continue prescribing an opioid medication previously prescribed for you. It may be determined that such a medication is not suitable. It is our policy that GPs do not prescribe drugs of dependence if they feel that previous prescriptions were inappropriate. • Your GP will evaluate your condition and only prescribe an opioid of the strength necessary for you. This may be different to the drug you had prescribed at your previous GP Practice. General practice standards: • If the decision to prescribe is taken after a shared discussion of goals, plans, risks and benefits, you may be required to confirm your consent in writing. • You will be asked to complete the Opioid Management Plan: Treatment Agreement that will detail our practice’s expectations when prescribing drugs of dependence. This agreement details your responsibilities as a patient taking a drug of dependence; any prescriptions issues; advice on taking your medications; how we will monitor your care; and the standards of behaviour that are expected. • Patients may need to acknowledge that their care requirements may be complex, and that referral for on-going care for all or part of your healthcare may be required. It is our practice policy that patient care is matched with the level of complexity. • Patients are reminded that we have a zero tolerance on issues relating to staff abuse.

Please sign below to agree to this policy*

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