Name__________________	Address________________________________________________
DOB___________________   	Telephones numbers _____________________________________
Nationality  ______________
Will you require an interpreter for GP appointments     NO            Yes        (please circle)

Women Aged 25-64
Date of Last Smear ___________

Height		__________
Weight		__________
Drug Allergies 	__________	Non Drug Allergies ________________
Smoking History - Current Smoker YES/Ex/Never    IF Smoker how many Daily ________
Alcohol weekly units __________
Are you a registered carer for someone – Yes /No … if yes for who __________________
Name of Community Pharmacy you want to use: ________________ 
Medical History				Yes 	No			Current Medication
Angina /Heart Attack							1______________
Heart Failure								2.______________
Stroke									3.______________
High Blood Pressure							4.______________
Diabetes								5.______________
COPD									6.______________	
Asthma						 			7.______________
Epilepsy								8.______________
Hypothyroidism								9.______________
Cancer									10._____________
Depression								11._____________
Atrial Fibrillation							12._____________
Significant Family History i.e Heart Attack/ Cancer _________________________________________
  __________________________________________________________________________________
Downe Health Centre
New Patient Practice Agreement
Name __________________________		Date of Birth ___________________________
Discloser
I agree to disclose all material fact regarding my health to my General Practitioner and his/her clinical staff. We the practice, declare that we shall not disclose any information regarding you without your written consent, unless required to do so by a court  order or any other obligations.
Confidentially
We declare that we shall hold all confidential matters pertaining to you and not release such information, expect in relation to managing you care (eg referral letter) without your written consent, unless required to do so by a court order or any other legal obligations.
Appointments 
I agree to arrive on time for all appointments that I book with the practice, or cancel in advance any appointment that I cannot attend. If I arrive late for my appointment I will only be seen at the discretion of the GP, based on his/her assessment on my clinical need, and that I may be advised to wait until the end of surgery or rebook for another day. Patients who continually miss appointments will be removed from the register, but only after getting a letter first.
Prescribing
I understand and agree that Downe Health Centre do not believe in prescribing benzodiazepines (such as Temazepam, Nitrazepam, Diazepam and Z drugs) unless directed by consultant or clinical need (short term only). Downe Health Centre cannot guarantee that they will issue opiates of benzos- and especially not on the day I register.  Patients on repeat medication will have their medication printed from the Electronic Care Register (ECR) at the point of registration. This will allow for safe prescribing and less delays issuing of medication.
Repeat Prescribing
I will give two working days’ notice when requesting a repeat prescription. The Practice have a dedicated prescription line for repeat medication 02844619547.
Zero Tolerance
I agree with the Policy of Zero Tolerance abuse toward all NHS staff and I agree not to behave in an abusive, threatening or otherwise aggressive manner with any member of the Practice Staff or others at the Clinic. I acknowledge the right of the practice to remove me form their list without appeal should I behave in a manner prohibited.
I can expect to receive equal respect and curtesy from the practice staff.
Signed ________________________		Date___________________