New patient additional information

Patient Details

Title:

Surname: *

First name(s): *

Home telephone:

If this is a mobile number, is it a family or a personal contact line?

Family

Personal

n/a

Work telephone:

Mobile number:

Email address: *

Are you happy to be contacted by email?

Yes

No

You will receive text appointment reminders to your mobile number unless you opt out. Tick here if you want to opt out.

Carers

Do you have a carer?

Yes

No

Are you a carer/do you look after someone?

Yes

No

Smoking Status

Do you smoke?

Yes

No

How many cigarettes do you smoke in a day?

Would you like smoking cessation advice?

Yes

No

Are you an ex-smoker?

Yes

No

How many cigarettes did you smoke per day?

Sensory or Communication Needs

Please specify if you have any sensory or communication needs:

Are you registering an infant for the first time?

Yes

No

Registering Newborn Infants

Parental Responsibility is a legal term that means having all the legal rights, duties, powers and responsibilities for a child (under the age of 18). A mother automatically has parental responsibility for her child from birth. A father usually has parental responsibility if he’s either married to the child’s mother or listed on the birth certificate (after 1 December 2003 in Wales).

Please list below persons who hold parental responsibility for the above named child. (We may request to see the birth certificate in some circumstances):

Contacting you

Do you give your consent to be contacted from time to time, via email and/or SMS, with practice news, advice about your health and or appointment reminders?

Yes

No

Signature: *