Application to Register Permanently with a General Medical Practice
This form must be completed as fully as possible.
1. Personal Details
2. Information to Help Trace Your Previous GP Health Records
3. If you are from abroad
4. If you have served in HM Armed Forces
New Patient Registration/Health Questionnaire
All information supplied will be recorded in your confidential medical records.
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Contact Details Smoking Alcohol
For the following questions please answer to the best of your knowledge.
We have provided a basic guide to alcohol content below to assist your completion.
A 750ml bottle of wine contains 10 units.
A standard(175ml) glass of wine contains 2 units.
A single small shot of spirits (25ml) contains 1 unit.
A standard 70cl bottle of spirits contains 28 units.
A pint of 3.6% strength lager/beer/cider contains 2 units.
A pint of 5.2% strength lager/beer/cider contains 3 units.
How many units of alcohol do you drink a week? Height & Weight - Please tell us your most recent measurements for the following (if known). Next of Kin Family History
The following information you supply may assist us to provide good care for you whilst we wait for your previous medical records. Is there any of the following in your family (father, mother, brother, sister) under the age of 65 with the following illnesses?
Please give details of any medication which you take (prescribed or otherwise). Please enter each drug on a separate line.
Name of drug - Dosage Please add a photo of your most recent repeat medication slip if you have one. Allergies If Yes, please give details Past Medical History Please give details of any treatments/medical conditions. Carer Information History Special Circumstances
Please tick any/all that apply.
Military Veteran Communication Do you have any communication / information needs relating to sensory loss and, if so, what are they and how would you like us to communicate with you? ACCEPTABLE BEHAVIOUR CONTRACT
We are committed to promoting access to our services and offering choice wherever possible in the services we provide and the way we deliver them. An acceptable behaviour contract is an individual written agreement between a patient and their GP practice.
The contract is between:
Your Name Date of Birth
and Bridgend Group Practice and is valid from the date shown in the signature table below.
Bridgend Group Practice will ensure you are dealt with quickly, fairly and in a courteous and helpful manner. Bridgend Group Practice will ensure that staff take responsibility for resolving or dealing with your query or that they refer it to an appropriate colleague.
The above-named person applying for registration at the practice agrees to the following:
1. To refrain from using abusive or offensive language, making threats of violence or aggressive behaviour and to treat all staff fairly and with respect; in person, on the phone, in writing or on social media.
2. To cancel any appointments they are unable to attend with as much notice as possible.
3. To Bridgend Group Practice’s DNA (Did Not Attend) policy - if they miss three appointments without notifying the surgery, they may be removed from the practice list and will have to register with a different practice.
4. To adhere to Bridgend Group Practice’s repeat prescription policy and agree to allow two working days before collecting repeat prescriptions.
Breach of this Contract:
If the above-named person fails to adhere to the above conditions, they may be removed from the practice list. This contract serves as an initial warning in the event of breaches occurring.
We now need you to provide proof of your identification and your address. We ask for 2 things: Step 1
A photo of your passport or driving licence, as proof of your name;
A photo of a recent utility bill or similar, from sometime over the past 3 months, as proof of your current address.
Please note that we use these items once for verification when setting up your account, and we delete them as soon as your account is open.