Next of Kin, Carers & Ethnicity Form

 

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To all patients, if you are applying to register and this form is not completed, your registration application form will not be accepted, ensure you have completed all boxes below.

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Personal Details
Please double check you've entered the correct email address
Next of Kin Information
Carers Information

A carer is someone who, without payment, looks after a friend, relative or neighbour who could not otherwise manage without their support.

Summary Care Record

A Summary care record will be created for you which will contain any medicines you are taking, allergies you suffer from and adverse reactions to medicines that you have had. This will allow healthcare staff to gain faster, easier access to essential information in the event of an emergency. Summary care record will consist of mediations, allergies & adverse reactions.

Ethnicity Information
Lifestyle Information

alcohol information

Electronic Prescription Services

Prescriptions: Sign up for EPS? (Electronic Prescription Services)
Your prescriptions will go electronicly to a Pharmacy of your choice, Locally or place of work.

Privacy Consent

This form collects personal and medical information about you. We use this information to confirm you are registered with the practice and to allow the practice team to contact you if applicable. The information you send helps us to update your medical records held by the practice and our partners in the NHS. Please read our Privacy Policy to discover how we protect and manage your submitted data.

 
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