Online Registration Form (patients aged 15 yrs and over) All information supplied is treated confidentially and forms a part of you medical record. Step 1 of 5 20% All patients registering at The Chislehurst Partnership will have full record view automatically enabled dating from the date of registration. Once you are registered for the Patient Access System you are able to; – make appointments – request prescriptions – view your GP medical record online If you would like to have secure online access to your historical records, we need to make sure that you understand what this involves and that you are happy for us to use the information provided below to set up and operate the service. If you wish to have historical access to your record, please complete and submit the Online Access Request FormName First Last Date of birth Day Month Year Home NumberMobile NumberPatients aged 13 years and over must supply an individual mobile number.Email address Enter Email Confirm Email (must be different for each individual)Address Street Address Address Line 2 City Postcode Occupation School currently attended Nominated Pharmacy for your medication (This is sent electronically)Please attach a copy of your latest list of medication to your application Optional Drop files here or Select files Max. file size: 50 MB. Are you are carer? Yes No Please give detailsDoes someone care for you? Yes No Please give detailsIs your first language English? Yes No First language Spoken Interpreter Required? Yes No What is your ethnic group?White – BritishWhite – IrishAny Other White backgroundMixed – White & Black CaribbeanMixed – White & Black AfricanMixed – White & AsianAny Other Mixed backgroundAsian or Asian British – IndianAsian or Asian British – PakistaniAsian or Asian British – BangladeshiAny Other Asian BackgroundBlack or Black British – CaribbeanBlack or Black British – AfricanAny Other Black BackgroundChineseOtherPlease specify Consent OptionsAll patients registered at this surgery will automatically have a summary care record created unless they have expressed a specific preference to opt out. To learn more, visit www.nhs.uk/your-nhs-data-matters or call 0300 303 5678 The Practice also has access to the Local Care Record. More information can be found on the website www.chislehurstmedicalpractice.co.uk. If you require further information regarding consent, please visit the Practice Website at www.chislehurstmedicalpractice.co.uk. Online AccessAll patients over 16 will automatically be enrolled for online access to their medical record for appointment booking and requesting medication. If you require access for anyone under 16 or full access to your record please complete the form at the end of this document. The surgery sends text reminders, recalls and urgent messages via text. It is your responsibility to notify us of any changes to your mobile number in writing.If you wish to receive reminders you MUST consent here I consent to receiving SMS text messages from the surgery I do not wish to receive SMS text messages from the surgery Getting in touch is sometimes difficult. Currently we do not leave voice messages without patient consent. Please indicate if you would like us to leave you a brief message. I consent for messages to be left on my mobile voicemail and understand my responsibility as set out below. OptionalIt is essential that you ensure that we have the most up to date mobile number for you. Updates to this information can be done when booking an appointment or in writing.In the future we may to wish to communicate with you via email. Please indicate if this would be a useful option for you and you would like to use this facility. I consent to receiving communication via email and understand my responsibility as set out below. OptionalIt is essential that you understand that you are responsible for ensuring that we have the correct email address and who has access to this information. Updates only accepted in writing or via our online change of details form. Medical QuestionnaireAll new patients can book a new patient health check. Please ask at Reception.Height Optional Weight Optional Smoking Status Never Smoked Optional Current smoker Optional Ex-smoker Optional Use electronic cigarette Optional Cigarettes per day Optional Date you gave up Optional (month/year)Are you allergic to anything? Yes Optional No Optional Please specify OptionalDate of MMR vaccination Day Optional Month Optional Year Optional Date of booster MMR Day Optional Month Optional Year Optional Do you know your HIV status? Yes Optional No Optional We can offer a confidential HIV test. Please ask at reception. We offer Hepatitis A & B vaccination if you are from an at risk area.Have any of your immediate relatives suffered from any of the following OptionalPlease Select..Angina or Heart AttackStrokeHigh CholesterolAsthmaDiabetesCancerHigh Blood PressureRelative e.g. mother, sister Optional Are they Under or Over 60? Under 60 Optional Over 60 Optional Please specify Optional Please add any other information that you would like the doctors to know about you. Please include any special requirements such as disability access Optional Alcohol: (Patients 15 yrs and over)In moderation alcohol can be part of a healthy lifestyle, but excessive alcohol can be harmful to you. We would be grateful if you could answer the following questions as honestly and accurately as possible. To help answer the questions, use the alcohol unit guide below to help estimate the amount of alcohol you drink. Alcohol Units – 2 units = 1 pint beer or 1 glass of wine (175mls) – 1 unit = single measure of spirits – 1.5 units = alcopop or a can of Lager – 9 units = 1 bottle of wineNo of units of alcohol per week Optional 1. How often do you have a drink containing alcohol? OptionalNever (0)Monthly or less (1)2 – 4 times per month (2)2 – 3 times per week (3)4+ times per week (4)2. How many units of alcohol do you drink on a typical day when you are drinking? Optional1 – 2 (0)3 – 4 (1)5 – 6 (2)7 – 8 (3)10+ (4)3. How often have you had 6 or more units if female, or 8 or more if male, on a single occasion in the last year? OptionalNever (0)Less than monthly (1)Monthly (2)Weekly (3)Daily or almost daily (4)Please score your questions. For example if the answer to question 1 is ‘monthly or less’ this will score 1 for that question Add your scores for questions 1-3. A total score of 4 or less for the above 3 questions is an indicator of a safe level of drinking. If you total score is 5 or more then please continue with questions 4-10.4. How often during the last year have you found that you were not able to stop drinking once you had started? OptionalNever (0)Less than monthly (1)Monthly (2)Weekly (3)Daily or almost daily (4)5. How often during the last year have you failed to do what was normally expected from you because of your drinking? OptionalNever (0)Less than monthly (1)Monthly (2)Weekly (3)Daily or almost daily (4)6. How often during the last year have you needed an alcoholic drink in the morning to get yourself going after a heavy drinking session? OptionalNever (0)Less than monthly (1)Monthly (2)Weekly (3)Daily or almost daily (4)7. How often during the last year have you had a feeling of guilt or remorse after drinking? OptionalNever (0)Less than monthly (1)Monthly (2)Weekly (3)Daily or almost daily (4)8. How often during the last year have you been unable to remember what happened the night before because you had been drinking? OptionalNever (0)Less than monthly (1)Monthly (2)Weekly (3)Daily or almost daily (4)9. Have you or somebody else been injured as a result of your drinking? OptionalNo (0)Yes, but not in the last year (2)Yes, during the last year (4)10. Has a relative or friend, doctor or other health worker been concerned about your drinking or suggested that you cut down? OptionalNo (0)Yes, but not in the last year (2)Yes, during the last year (4)Total Optional If you have completed questions 4-10 this may indicate that there is a potential health implication due to drinking alcohol. We invite you to make a routine appointment to discuss this further. Next of KinPlease complete as much detail as possible.Relationship to patient Optional Name Dr.MissMr.Mrs.Ms.Mx.Prof.Rev. Title Optional Given name Optional Surname Optional Address Street Address Optional Address Line 2 Optional City Optional Postcode Optional Home Telephone OptionalWork Telephone OptionalMobile Telephone OptionalPlease upload your proof of address Optional Drop files here or Select files Max. file size: 50 MB. Email OptionalThis field is for validation purposes and should be left unchanged.