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Permanent Registration Form Age 16+

Thank you for your interest in joining our Middlewood family.

Please take the time to fill in the form. It may take a little time as it is quite detailed but will allow to have some background information to help us help you from day one of your time with us.

It can take some time for your medical records to arrive with us and so this will allow us to treat you whilst we wait.

If you are unable to answer any questions please leave them blank and this can be picked up in your new patient appointment.

Step 1 of 2

Permanent ADULT Application Form*
- Permanent ADULT Application
The person named in this application is over the age of 15 if not then you need to complete the Permanent Registration Form for a Child.
Name*
Prefix First/Given Name Middle Name(s) Last/Family Name
Date of Birth*
DD slash MM slash YYYY
NHS Number

This will help to speed up the process. You will find this 10 digit number on a repeat prescription or by contacting your current surgery.
Previous Surnames
Town & Country of birth:*
Address*
1st Line of Address City County Postal Code
Landline/Mobile*
Mobile
Email Address
Enter Email Confirm Email

Needs to be an individual to each registration
Previous Address*
1st line of Address City County Postal Code Country
Previous GP Surgery*
Previous GP Surgery address
Ethnic Origin
Gender*
- Male
- Female
Date of entry into the UK (if applicable)
MM slash DD slash YYYY
Have you undergone gender reassignment?
- Yes
- No
I consent to receive SMS notifications for clinical and administrative use*
I consent to receive Email notifications for clinical and administrative use*

	Mother	Father	Sister	Brother	Aunt	Uncle	Maternal Grandma	Maternal Grandad	Paternal Grandma	Paternal Grandad	Yes unsure who	Don't know
Have any relatives suffered from Ischaemic heart dis <60?
Have any relatives suffered from Ischaemic heart dis >60?
Have any relatives suffered from asthma?
Have any relatives suffered from hypertension?
Have any relatives suffered from Epiliepsy??
Have any relatives suffered from cerebrovascular accident (Stroke)?
Have any relatives suffered from cancer?
Have any relatives suffered from Diabetes Mellitus?
Have any relatives suffered from Rheumatoid Arthritis??

	Never	Monthly or less	2-4 times per month	2-3 times per week	4+ times per week
How often do you have a drink containing alcohol?

	0	1-2	3-4	5-6	7-9	10+
How many units of alcohol do you drink on a typical day when you are drinking?

	Never	Less than monthly	Monthly	Weekly	Strongly agree
How often have you had 6 of more units if female, or 8 or more if male, on a single occasion in the last year?