QUAYSIDE MEDICAL PRACTICE

Patient Registration Form — Over 16

Please complete all sections that apply to you as fully as you can. Fields marked with an asterisk (*) are required. You can save time by completing this on screen, then downloading a copy to bring in or email to us.

Please note If you have been removed from your previous practice under the special allocation scheme within the last 12 months, you will be unable to register at this practice. You will have been notified of your allocated practice by NHS England.

How this works

  1. Fill in the sections below that apply to you. You can move between sections using the tabs, and come back to this page any time — your answers stay on screen until you close the tab.
  2. Download your completed form. On the last section, click "Download / print my completed form" and choose Save as PDF in the print window that opens. This saves a copy to your device.
  3. Send it back to us, either way: email the saved PDF to r.quayside@nhs.net, or bring the printed or saved copy with you to reception. If you have them, please also bring photo ID (passport or driving licence) and proof of address with your name on it (utility bill, council tax bill or bank statement). You do not need them to register.

We use the information on this form to register you and provide your care. Read our privacy notice. When emailing, only send the form to r.quayside@nhs.net.

1. Background Details

NHS Number

If you've had a previous GP, you'll find this on letters or prescriptions, or at nhs.uk/find-nhs-number.

Personal details
Which of the following best describes how you think of yourself?
Is your gender the same as the sex you were assigned at birth?
Address & contact

It's your responsibility to keep us updated with any changes to your phone number, email and postal address. We may contact you about appointments, test results, health campaigns or the Patient Participation Group.

Next of kin
Family & NHS history
Have you been registered in the NHS before?
Ethnicity (optional)
Religion (optional)
Housing
Employment
Overseas visitor / Armed forces
Communication needs
Do you need an interpreter?
Do you have any communication needs?
If yes, please specify
Do you have a learning disability?

If yes, please ask us for a Learning Disability Screening Tool form.

Carer details
Are you a carer for someone else?
Do you have a carer? (only add these details with the carer's consent)

2. Medical History

Have you suffered from any of the following conditions?
Family history

Please record any significant family history of close relatives with medical problems.

Allergies
Vaccinations
Have you had all your routine vaccinations?
Did you get all your routine vaccinations in the UK?
Current medication

3. Your Lifestyle — Alcohol (AUDIT-C)

These are validated screening questions for alcohol use. Please answer as accurately as you can.

AUDIT-C total: 0

A score of less than 5 indicates lower-risk drinking. A score of 5 or more requires the following 7 questions to be completed.

Full AUDIT questions

AUDIT total: 0

Smoking

Do you smoke?
Do you use an e-cigarette?
How many cigarettes did/do you smoke a day?
Would you like help to quit smoking?

For further information, see nhs.uk/smokefree.

Height, weight & measurements

Women only

Do you use any contraception, or have a coil or implant in situ?
Are you currently pregnant, or think you may be?

Students only

Students are at higher risk of certain infections including mumps, meningitis and sexually transmitted infections, as well as mental health issues including stress, anxiety and depression. See nhs.uk/livewell/studenthealth.

I am less than 24 years old and have had two doses of the MMR vaccination
I am less than 25 years old and have had a Meningitis C vaccination

4. Further Details

How well do you use a mobile phone or the internet to communicate with your GP practice?
Electronic prescribing
Patient Participation Group

We are committed to improving the services we provide. The Patient Participation Group gives us valuable feedback from patients about their experiences, views and ideas for improving our services.

Would you like to be involved in our Patient Participation Group?
Blood and organ donation

Interested in donating blood? Visit blood.co.uk.
Interested in registering your organ donation decision? Visit organdonation.nhs.uk.

5. Sharing Your Health Record

What is this, and why does it matter? (read before answering)

What is your health record? It contains all the clinical information about the care you receive — medical history, medications and allergies — so clinicians can help you safely wherever you're seen.

Is it secure? Yes — safeguards ensure only organisations you've authorised can view it, and you can ask who has accessed it.

Can I change my mind? Yes, at any time — just let us know.

Things to consider before agreeing to share: your record may contain something you'd forgotten and find upsetting; you might see abnormal results or bad news before speaking to your doctor; sharing information with family or carers is your choice and your responsibility to keep secure; if you feel pressured by someone to reveal details from your record, it's best not to consent to sharing at this time; some content can be technical — contact the surgery for a clearer explanation; if you spot information that isn't about you, log out and contact the practice immediately.

Do you consent to your GP Practice sharing your health record with other organisations who care for you?
Do you consent to your GP Practice viewing your health record from other organisations that care for you?
Do you consent to having an Enhanced Summary Care Record with additional information (e.g. care plans)?

6. Access to GP Online Services

Important information — please read before completing

You can use the internet (via computer or mobile app) to book GP appointments, request repeat prescriptions and view your medical record online — or continue using the phone or in-person as usual. It's your choice.

It is your responsibility to keep your login details and password safe. If you suspect your record has been accessed without your agreement, change your password immediately, or contact the practice to remove online access until you can reset it.

If you print information from your record, it's also your responsibility to keep that secure.

During the working day, practice staff sometimes update your record (e.g. attaching a received document) — you may notice admin/reception names alongside some entries; this is normal.

Please bring photographic proof of identification so the sign-up process can be completed. For further information, see nhs.uk/nhsengland/aboutnhsservices/doctors/pages/gp-online-services.aspx.

I wish to have online access to: (tick all that apply)
I wish to access my medical record & understand and agree with each statement: (tick all that apply)

7. Declaration & Signature

By typing your name below and ticking the declaration, you are confirming the information you have provided is true to the best of your knowledge. This applies to both the registration form and, if completed, the online access request above.

STAFF ONLY

8. For Practice Use Only

Patients: you can skip this section — it's completed by practice staff when your registration is processed.

Checklist
Appointment
Photo ID
Proof of address
Identity verified through