Homeless Registration Form

Step 1 of 11

About you

Title Required

Title (other) Required

First name Required

Last name Required

Previous surname/s Optional

Gender Required

Date of birth Required

Day

Month

Year

Place of birth Required

NHS number (If known) Optional

Contact details

Address RequiredIf you do not have an address to give, please use the surgery address.

Street Address Address Line 2 Town Postcode

Telephone/Mobile number Required

Email address Optional

Can we contact you by text? Required

Can we contact you by email? Optional

Ethnic group

White Optional

British

Irish

Irish Traveller

Traveller

Gypsy/Romany

Polish

Any other white background

Mixed Optional

White and Black Caribbean

White and Black African

White and Asian

Any other mixed background

Asian or Asian British Optional

Indian

Pakistani

Bangladeshi

Any other asian background

Black or Black British Optional

Caribbean

African

Somali

Nigerian

Any other black background

Other ethnic group Optional

Chinese

Filipino

Any other ethnic group

Not stated

What is your main language? Required

Emergency Contact Information

Name Optional

First Name Optional Last Name Optional

Relationship to you Optional

Contact Number Optional

Are they your next of Kin? Optional

Do you give us permission to contact them in an emergency? Optional

Extra Information

Do you have any allergies? (this includes drug allergies) Required

If yes, please state what allergies and the severity: Optional

Armed Forces Status Required

Extra Information continued

Are you a carer? Required

If yes, please state the name of who you are caring for, and their relationship to you: Optional

Are you being cared for? Required

If yes, please provide the following details of your carer: Optional

First Name Optional Last Name Optional

Contact Number Optional

Please state their relationship to you: OptionalThey could be a relative or just a carer.

Do you give us permission to your medical record with your carer if required? Optional

General Health

What is your height in cm? Optional

What is your weight in kg? Optional

If you're able, please provide a blood pressure reading: Optional

What is your eye sight like? Required

How is your hearing? Required

Please let us know if you have any other needs or requirements: Optional

General Health Continued

Smoking Status Required

How much exercise do you do per week? Required

How often do you drink alcohol? Required

How many units of alcohol do you typically drink on a typical day when you are drinking? Required

How often do you drink 6 or more units ? Required

Last Smear

Only female patients over 25 years old need to fill this section out

What is the date of your last smear? Optional

Day Optional

Month Optional

Year Optional

Smear Result (if known) Optional

Family History

Have any members of your family been diagnosed with the following: stroke, heart attack, diabetes, asthma, cancer or another serious illness not stated Optional

If yes, please state which family member, their relationship to you and what they had: Optional

Would you like to participate in our virtual patient group? RequiredThis is for the occasional survey or newsletter via email.

Do you give consent for a Summary Care Record? RequiredSummary Care Record (SCR) is a national database that holds electronic records of important patient information such as current medication, allergies and details of any previous bad reactions to medicines, created from GP medical records. It can be seen and used by authorised staff in other areas of the health and care system involved in the patient's direct care, with the patients consent.

Pharmacy Nomination Required

A nominated pharmacy is where we will send your prescriptions electronically to. As a new patient, if you are on any medication, please make an appointment to speak to the GP before you need further prescriptions.

Pharmacy Name Address Line 1 City County Postcode

Submitting ID

If you do have ID, please provide it. however this is not a requirement for this type of registration.

Photographic ID OptionalThis can be drivers license, passport, bus pass etc.

Max. file size: 128 MB.

Proof of Address OptionalThis can be a utility bill, bank statement, rent agreement etc.

Max. file size: 128 MB.

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Homeless Registration Form