Register - Devizes Primary Care Network

Register with one of our practices today

To register as a patient with one of our practices, please complete the form below. Please ensure that you specify which practice you wish to register with on the form. Once your chosen practice has confirmed your registration, you will be able to download the NHS App so that you can access all services online.

Surname

Previous Surnames

First Name(s)

Date of birth:

Gender: MaleFemaleIndeterminate

NHS Number

Town and Country of birth

Home Address

Postcode

Your email address

Home Phone Number

Mobile Phone Number

Work Phone Number

Can we contact you by text? YesNo

Can we contact you by email? YesNo

Registration Type:

Ethnicity

Please specify the ethnic group you consider you belong to: White BritishWhite IrishBlack CaribbeanBlack AfricanBlack Caribbean and WhiteBlack African and WhiteIndianPakistaniBangladeshiI do not wish to stateOther ethnic group

Do you speak English? YesNo

Do you read English? YesNo

First Language

Emergency Contact

Full Name

Relationship to you

Phone Number

Are they your next of kin? YesNo

Do you give us permission to discuss your medical records with them? YesNo

Allergies

Do you have any allergies? YesNo

List allergies if you have any

Previous Details

Previous address in UK

Name and address of previous GP

If you are from abroad

Date you came to live in the UK:

If you are returning from abroad

Date you left the UK:

Date you returned to the UK:

Have you ever served in the British Armed Forces?

Service or Personnel Number

Date enlisted:

Date returned

Address prior to enlisting

Supplementary Questions

I am not ordinarily a resident in the UK

European Economic Area (EEA) Country

For a list of EEA countries visit: www.gov.uk/eu-eea

Do you live in another EEA country, or have moved to the UK to study or retire, or live in the UK but work in another EEA member state? YesNo

Carers

Do you have a carer? YesNo

Are you a carer for someone YesNo

Name of Carer

Phone Number

Carer Address

Permission to discuss medical information with your carer YesNo

Lifestyle

Smoking Status Current smokerEx smokerNever smoked

If yes, how many cigarettes do you smoke a week?

Do you wish to stop smoking YesNoNon-applicable

*We offer a smoking cessation service please ask for information

Height

Weight

Alcohol questions:

How often do you have a drink? NeverMonthlyWeeklyDaily

How many drinks do you consume?

Sight: GoodPartly sightedRegistered blind

Hearing: GoodPartly deafRegistered deaf

Medical Background:

Please provide any current and past medical history:

What illnesses have you had and when?

What operations have you had and when?

Do you have any medical problems at present?

Please list any tablets, medicines or other treatments you are taking

Are there any diseases that affect your Parents, Brothers or Sisters (tick all that apply)?

DiabetesHeart AttackHeart attack under the age of 60Bowel CancerBreast CancerHigh Blood PressureAsthmaStrokeThyroid DisorderAny other illness (please detail below)?

Other

Which pharmacy would you like your medicine to go to? MorrisonsDevizes PharmacyBootsOther (please specify below)

Other

Do you have any specific needs?
Please detail below any specific needs you have to the Practice can ensure they are identified and accommodated by taking he appropriate action:

Please state any sensory impairment you have

Are you an 'Assistance Dog' user?

Please state any physical disabilities you have

Please state any mental disabilities you have

Please state any requirements to be able to access the Practice premises

Please state any Religious or Cultural needs

Do you require the help if a Translator / Interpreter?

Please state any nutritional requirements you have

Please state any allergies and sensitivities you have

Please state any phobias you have

Sharing information

There may be occasions when it is necessary to share your information with other Health organisations (Hospitals, Health teams, Social care, Out of hours etc.) in order for you to receive the best care and service. There is a formal information sharing agreement in place with these organisations. To help us provide you with the best service only relevant information will be shared with these organisations when necessary.

Do you consent to relevant information the the surgery record about you being accessible where necessary with other NHS/ Social care services?

Do you consent for the surgery to view information about you that has been recorded on your record by other service providers where you have received care?

Where necessary do you consent to wounds being photographed and added to your medical records if deemed appropriate, for the purpose of treatment monitoring?

Make an enquiry online using this form and one of our team will be in touch. By using this form you agree with the storage and handling of your data by our team.