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The Maples Health Centre NHS GP Surgery in Hertfordshire

Adult new patient registration (16 and over)

To register a child under 16 years of age with the practice please complete our Child New Patient Registration form (under 16)

Patient’s Details

Title *

Mr

Mrs

Miss

Ms

Other

Please specify:

Surname: *

Previous Surnames:

First Name(s) *

Date of Birth: *

Please use this date format: DD/MM/YYYY.

Gender at Birth: *

Male

Female

NHS Number:

If you were previously registered at another practice please contact the practice to obtain your NHS No.

Are you registering from a care home?

Yes

No

Is your care home residency:

Temporary

Permanent

Home Address: *

Postcode: *

Please check you live within our Practice Boundary before submitting this form.

Town and Country of birth: *

Do you identify as Transgender?

Yes

No

What gender do you identify as?

Male (including trans man)

Female (including trans woman)

Non-binary

Other

Please specify:

Previous Details

Previous address in UK: *

Please include postcode.

Name and address of previous GP: *

Electronic Prescription Service (EPS)

The Electronic Prescription Service (EPS) is a NHS service that allows us to send your prescription(s) directly to your chosen pharmacy. This paper-free prescription service means that you do not have to come into the surgery to collect your prescription.

Please request your prescriptions in the normal way through your surgery.

If you do not nominate a pharmacy then we will assign you to the pharmacy nearest to your home address – but this can be changed at any time.

Do you already have a nominated pharmacy?

Yes

No

Would you like to stay with your nominated pharmacy?

Yes

No

My chosen Pharmacy is: *

Pharmacy Name: *

Pharmacy Address: *

Pharmacy Postcode: *

If you are from abroad

Your first UK address where registered with a GP:

Date you came to live in the UK:

Please use this date format: DD/MM/YYYY.

Contact Details

Home Phone Number:

Mobile Phone Number:

Work Phone Number:

Can we contact you by phone? *

Yes

No

Email Address: *

Can we contact you by email? *

Yes

No

Would you like to register for online services?

Yes

No

Registering for online services allows you to book and cancel appointments, order repeat prescriptions, changes your contact details and review your medications and known allergies

Status

Single

Married

Separated

Divorced

Widowed

Cohabitating

Disability

Do you consider yourself to have a disability?

Yes

No

Physical impairment (please specify)

Sensory impairment (please specify)

Learning disability/difficulty (please specify)

Mental Health condition (please specify)

Other (please specify)

Ethnicity

Please specify the ethnic group you consider you belong to:

Do you speak English?

Yes

No

Do you read English?

Yes

No

First Language:

Emergency Contact

Full Name:

Relationship to you:

Phone Number:

Are they your Next of Kin?

Yes

No

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

Yes

No

Please submit a signed document to this purpose as soon as possible. Your request will not be acted upon until the authority is received at the practice.

Allergies

Do you have any allergies?

Yes

No

Please specify what you are allergic to, what happens and when you had your first reaction:

Carers

Do you have a carer?

Yes

No

Name of carer:

Phone Number:

Address:

Do you give us permission to discuss your medical record with your carer?

Yes

No

Please submit a signed document to this purpose as soon as possible. The above request will be added to your record but will not be acted upon until the authority is received at the practice.

Are you a carer for someone? *

Yes

No

What type of carer are you? *

An employed carer (receive a salary for caring)

An unpaid carer (informal carer but can still receive benefits attached to caring for someone)