New Patient Questionnaire V3

Updated 28th April 2022

Please answer as fully as possible.  If you have any queries when completing this form please speak to a member of staff who will be happy to assist you.  All information will be held in your personal health record and remains confidential.

Last Updated: 29/04/2022

Questionnaire date:

Your Contact Details

Next of Kin

Other registered household members

Information About You

We collect this information as it is directly relevant to your health care needs and is often required when a referral is needed.


Carers and Armed Forces



1 unit = 1/2 pint beer/larger/cider

or 1 small glass of wine

or 1 single measure of spirits


Patient Authority - Prescriptions

If you wish for someone else to collect your prescriptions on your behalf, you will have to provide the Surgery with written consent.

This consent will remain in force until further notice or cancellation by me.

Contacting You/Leaving Messages

In accordance with the Data Protection Act, our Surgery requires written consent from any patient who has an answerphone and is happy for our staff to leave a message.  If we do not have consent we will be unable to leave a message on an answerphone or with any third party (ie to notify a change or cancellation of an appointment).

If we do not have consent, we will be unable to send you a message or get in touch with a third party (unless it is thought to be a medical emergency)

Additional Information

Patient Participation Group

The Patient Participation Group are a committed group of patients, staff and members of the community, who work collectively as a voluntary group to support the Partners and Practice Manager in the effective runing of the Practice.

To sign up to receive a copy of our newsletter via email please visit the main website and click on the Practice Newsletter section at the bottom.

Summary Care Record

Summary Care Records are in operation in the NHS for each patient that will be used for emergency care.  The record will contain information about any medication you are taking and any allergies or bad reactions to previous medications you have had, to ensure those caring for you have enough information to treat you safely.  Please speak to a member of staff if you feel you need more general information or information on the opt out procedure.

Your Data Matters to the NHS

Information about your health and care helps us to improve your individual care, speed up diagnosis, plan your local services and research new treatments.

In May 2018, the strict rules about how this data can and cannot be used were strengthened.  The NHS is committed to keeping patient information safe and always being clear about how it is used.

You can choose whether your patient information is used for research and planning.  To find out more visit:

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