New Patients

Thank you for expressing an interest in becoming a patient at Woodbrooke Medical Practice. A new patient booklet is available from the surgery which explains the services we offer and our opening hours.  We would encourage you to read the contents carefully and decide if the services we provide meet your needs, before you apply to join the practice. To register:

•	Complete a New Patient Questionnaire
If possible attach a print out of your medication and vaccination history from the surgery you are currently registered with. We may verify your medication with your last GP before any prescriptions are issued to you.

•	Provide verification of your current address 
To confirm that you live within the practice area. A list of acceptable documentation is on the New Patient form. This must be within the last 3 months.  

•	Provide a Medical Card
If you do not have a Medical Card,and are transferring from a GP surgery in NI or you are transferring from a GP Surgery in GB where you have been registered within the last 12 months you will need to complete a HS200 form and provide supporting documentation, to request a new card or a replacement.

If you are a cross border worker or have not been registered with a GP in the last 12 months, or have lived outside the UK for more than 1 year or have never been registered for health care in NI, you will need to complete an HSCR1 form and provide supporting documentation will be required to allow your entitlement to medical care in Northern Ireland to be assessed.

When your forms are fully completed you should bring them with your supporting documents to reception for processing. Please note this can take up to 20 minutes per person. 

You will then be contacted by a practice nurse to complete a New Patient Medical consultation, by telephone. This appointment provides us with an opportunity to discuss your medical history and current medication with you and answer any questions you have about the practice.    

If for any reason we are unable to accept you as a patient, we will inform you in writing of the reason why registration has been refused.  

Patients are asked to inform us of any changes to their contact details to ensure we can reach them should the need arise. The Practice affords a high level of care to our patients and encourages feedback on the services we provide.  We also operate a zero tolerance policy with regard to inappropriate behaviour.  

Should you have any questions about registration or the Practice in general, our reception staff will be happy to assist.

Yours sincerely

Joy Thompson
Practice Manager				

REGISTERING WITH WOODBROOKE MEDICAL PRACTICE

New Patient Questionnaire

Please complete this form, answering all questions.

Have you been registered with this practice before?    Yes 	      	No 

Personal Details

Title:								Sex: Male		Female
First Name(s):									
Surname:										
Previous Name(s):									
Name Known By:									
Date of Birth:							
Place of Birth:		__________			

Ethnicity (Please tick):	British/Mixed	Irish			Other White						Asian			Indian			Pakistan						Other Asian		Caribbean		African						Chinese
Do you require an Interpreter?		   	Yes			No

Current Address							Previous Address

House Name / No.:						_______________________ 
Street:								_______________________
City / Town:								_______________________ 
County:							 	_______________________             
Postcode:								_______________________

Telephone Numbers

Home:  			  	Mobile: 			      Work:  			___

Your Current GP

Name of your current / last GP:								

Have you been registered with this GP in the last 12 months? Yes 	 No

Contact Details		Address:							

				Tel No.:							

Health & Care No.:			__________				

Medical History

Please tick any medical conditions you have at present:

Asthma				COPD			High Blood Pressure	

Epilepsy				Stroke			Heart Condition 

Diabetes 				Cancer			Kidney Disease
Mental Health Condition (Dementia  /  Depression  / Learning Disability)
Others:												
						
Allergies:												
												
Previous operations:										

Females Only:	

When was your last Cervical Smear?									
Have you a history of abnormal smears?		Yes		No

Family History:	
	
Please tick any of these illnesses that run in your family:	

Asthma				COPD			High Blood Pressure	

Epilepsy				Stroke			Heart Condition 

Diabetes 				Cancer			Kidney Disease
Mental Health Condition (Dementia  /  Depression  / Learning Disability)

Other(s) please list:										

Social Work Involvement

Is there a social worker involved with you or your children?	Yes 		No
If yes please give the social worker’s name & contact details

_________________________________________________________________

						
If no has there ever been social worker involvement?		Yes 		No
If yes please give details of social worker/social services department

Medications

Please list your current medication below OR attach a list from your current GP

Drug Name	Strength	Dose & Frequency	

			

			

			

Immunisations:

Please indicate your vaccination history or attach a list from your current GP.

Vaccinations	Completed	Date	
	Yes	No		
Childhood – 8 week				
Childhood – 12 week				
Childhood – 16 week				
Childhood – 1 year				
Childhood – Pre-school				
HPV				
Influenza				
Other immunisations (list): 

				

General Health & Information:

Smoking 		Current smoker		

			Ex-smoker
			Never smoked

Alcohol		Do you drink Alcohol?		Yes 		No	
			
			How many units a week?			

							
Help at home	Are you a carer?			Yes 		No

			
			Do you have a carer?		Yes 		No		

Please bring this form to reception with your supporting documents. An appointment will be made for you to attend a New Patient Medical. Please ensure you have adequate supply of medication from your current GP before you register. 

By signing this form, you are providing consent for the Practice, to contact your current / last GP to clarify your current medical conditions, treatment and medication and / or access your Electronic Care Record for the same purpose.

Date:						Signature:							

____________________________________________________________________

OFFICE USE ONLY

Registered Before?	Yes	    	No	    		Previous EMIS No.			

Forms Completed In Full			    				

Medication List (from current GP)		            
		
Proof of Address:	Driving License 	     		Home Insurance 	    	    
		Rates Bill		    		Mortgage / Tenancy	    		
			Bank Statement 	     		Housing Benefit	    	    
			HMRC		 	     		State Benefit		    					Utility Bill	 	     		S/Security Benefit	    					State Pension	 	     		Tax Credit Award	    	
			
			(Note: Proof of address is practice retained and does not need to go to BSO)

Forms & ID			       
•	Currently registered in NI:	
Medical Card 		     		
HS200			    		    
OR
•	Currently registered in GB - Born in the UK (inc. NI) 
Passport		    	
D/Licence		    	AND		HS200		    		    
Citizen Card		    		    
OR
•	Currently registered in GB - EEA Nationals (inc. born in ROI)        
Passport		    	
Birth Cert		    	AND		HS200		    		    
EEA Nat ID Card 	    	
OR
•	Currently registered in GB - Non-EEA Nationals	            
Passport		    	AND		Visa		    	AND 	      HS200	    	   
 
•	NOT Currently registered in GB / NI (inc. born in ROI):	        
HSCR1		    	AND		Supporting docs on back of form		    			         

New Patient Medical 						EMIS No. Allocated	 		

Receptionist: 		________________