New Patients

Thank you for expressing an interest in becoming a patient at Woodbrooke Medical Practice. A new patient booklet is available from the surgery which explains the services we offer and our opening hours.  We encourage you to read the contents carefully and decide if the services we provide meet your needs, before you apply to join the practice. To register:

•	Complete a New Patient Questionnaire
If possible attach a print out of your medication and vaccination history from the surgery you are currently registered with. We may verify your medication with your last GP before any prescriptions are issued to you. 

•	Provide verification of your current address & confirmation of your identity
Confirm that you live within the practice area; a list of acceptable address documentation is on the New Patient form, which must be recent (within the last 3 months). Confirm your identity using in date Photo ID if you need to complete an HSCR1 form (see below).

•	Provide a Medical Card
If you do not have a Medical Card, and are transferring from a GP surgery in NI or you are transferring from a GP Surgery in GB where you have been registered within the last 12 months you will need to complete a HS200 form and provide supporting documentation, to request a new card or a replacement.

If you are a cross border worker or have not been registered with a GP in the last 12 months, or have lived outside the UK for more than 1 year or have never been registered for health care in NI, you will need to complete an HSCR1 form and provide supporting documentation will be required to allow your entitlement to medical care in Northern Ireland to be assessed.

When your forms are fully completed you should bring them with your supporting documents to reception for processing; this can take up to 20 minutes per person. 

You will then be contacted by the practice to complete a New Patient Medical consultation, by telephone. This appointment provides us with an opportunity to discuss your medical history and current medication with you and answer any questions you have about the practice. 

If for any reason we are unable to accept you as a patient, we will inform you in writing of the reason why registration has been refused.  

Please inform us of any changes to your contact details to ensure we can reach if needed. The Practice affords a high level of care to our patients and encourages patient feedback.  We also operate a zero tolerance policy with regard to inappropriate behaviour.  

Should you have any questions about registration or the Practice in general, our reception staff will be happy to assist.

Yours sincerely

Joy Thompson
Practice Manager				

REGISTERING WITH WOODBROOKE MEDICAL PRACTICE

Medication
Please note when joining the practice that Pregabalin medication has been removed from the NI Formulary (recommended prescribing list) 
for chronic pain. 
We do not prescribe this medication
even if it has been prescribed 
before joining the surgery.

NEW PATIENT QUESTIONNAIRE

Please complete this form in CAPITALS, answering all questions

Have you been registered with this practice before?    Yes 	      	No 

Personal Details
Title:								
First Name(s):											
Surname:												
Name Known By:											
Previous Name(s):											
Date of Birth:						Place of Birth: ________		

Gender:

Gender at birth: 				Male		Female
Gender you currently identify as:	Male		Female		Other
Please note we must record your gender as male / female for screening purposes

Ethnicity:

British/Mixed	Irish			Other White			Asian		

Indian			Pakistan		Caribbean			Other Asian	
African		Chinese

Main spoken language:	English	Other	(please specify) _____________	

Do you require an Interpreter?		Yes				No
			Language (please specify)    ________________								
Current Address							Previous Address
House Name / No.:						_______________________ 
Street:								_______________________
City / Town:								_______________________ 
County:							 	_______________________             
Postcode:								_______________________

Telephone Numbers
Home:  			  	Mobile: 			      Work:  			___
Your Current GP
Name of your current / last GP:									
Address:									

			       Tel No.:									

Have you been registered with this GP in the last 12 months? Yes 	 	No	

Health & Care No.:			__________					

Medical History

Please tick any medical conditions you have at present:

Asthma		   COPD			High Blood Pressure	  Epilepsy

Stroke		   Diabetes		Heart Condition		  Kidney Disease
Cancer		   Mental Health 	Learning Disability

Other:												
						
Allergies:												
												
Previous operations:										

Cervical screening:	Date of last smear  				 (females only)

History of abnormal smears		Yes		No

Visual Impairment:		Do you have a visual impairment?	Yes		No
If yes please indicate the severity ____________________________		

Hearing Impairment:	Do you have a hearing impairment?	Yes		No
If yes please explain the communication support you require to use our services
(BLS interpreter / VRS / loop system / other) __________________________	

Family History	

Please tick any of these illnesses that run in your family:	

Asthma		 COPD		 High Blood Pressure	  Epilepsy

Stroke		 Diabetes		 Heart Condition		  Kidney Disease
Cancer		 Mental Health 	 Learning Disability

Other:												

Social Work Involvement
Is there a social worker involved with you or your children?	Yes 		No
If yes please give the social worker’s name & contact details
_________________________________________________________________

						
If no has there ever been social worker involvement?		Yes 		No
If yes please give details of social worker / social services department

Medication
Please list your current medication AND attach a list from your current GP
Drug Name	Strength	Dose & Frequency	

			

			

			

Immunisations
Please list your vaccination history AND attach a list from your current GP
Vaccinations	Completed	Date	
	Yes	No		
Childhood – 8 week				
Childhood – 12 week				
Childhood – 16 week				
Childhood – 1 year				
Childhood – Pre-school				
HPV				
Influenza				
Other immunisations (list): 

				

General Health & Information

Smoking & Alcohol:
I am a:	  Current smoker		Ex-smoker		Have never smoked

									
Do you drink Alcohol?	Yes 		No		How many units a week?	___       

							

Carers:	Do you have a carer?			Yes 		No			
Are you a carer for someone else? 	Yes 		No
		
Communication:

To allow us to communicate with you effectively, please indicate if you consent to:

Consent for SMS Text messaging			Yes 		No	

Patient Access On-line Service			Yes 		No	
Pharmacy collections for prescriptions 		Yes 		No	
If yes which Pharmacy would you like to nominate?				   _______ 
			
Please bring this form to reception with your supporting documents. 

If required an appointment will be made for you to attend a New Patient Medical. 

**Please ensure you have adequate supply of medication
from your current GP before you register with us**

By signing this form, you are providing consent for the Practice, to contact your current / last GP to clarify your current medical conditions, treatment and medication and / or access your Electronic Care Record for the same purpose.

Date:						Signature:							

OFFICE USE ONLY

Forms Completed in full	Yes	    	No         	        
	 	
Registered Before?	           Yes	    	No              Previous EMIS No.			

Medication:	 List (from current GP)			OR	ECR Print out		    
		
Proof of Address:	Driving License 	     		Home Insurance 	    	    
		Rates Bill		    		Mortgage / Tenancy	    		
			Bank Statement 	     		Housing Benefit	    	    
			HMRC		 	     		State Benefit		    					Utility Bill	 	     		S/Security Benefit	    					State Pension	     		Tax Credit Award	    		
(Note: Proof of address is practice retained and does not need to go to BSO)

Forms & ID	      

Currently registered in NI:	
	Photo ID
	Medical Card 	     		
	HS200		    		    

OR	Currently registered in GB - Born in the UK (inc. NI) 
	Passport		    	
	D/Licence		    	AND		HS200		    		    
	Citizen Card		    		    

OR	Currently registered in GB - EEA Nationals (inc. born in ROI)        
	Passport		    	
	Birth Cert		    	AND		HS200		    		    
	EEA Nat ID Card 	    	

OR	Currently registered in GB - Non-EEA Nationals	            
	Passport		    	AND		Visa			    	AND 	 HS200         	   

OR	NOT Currently registered in GB / NI (inc. born in ROI):	        
	HSCR1		    	AND		Supporting docs	    	
							on back of form

Alerts & Coding
Message Alert  	Parents EMIS	No.	Yes		No		N/A

Coded			Interpreter		Yes		No		AND 	Message Alert	

			SMS Text		Yes		No	

			Patient Access	Yes		No

			Current	  	Smoking		Alcohol	

			Carer			Yes 		N/A		AND 	Message Alert	

Added			Pharmacy 	 	Yes		No	

EMIS No. Allocated		 				
Receptionist: 		________________     	     Signature _________________