Untitled - The Villages Medical Group

Online Registration With The Practice

If you are looking to register with The Villages Medical Group digitally!, Please complete as much of this information below as possible – Meaning we can get your record up to date quickly! At the end you will be asked to upload photo ID, This must included a photo ID, and a recent paper document such as a Bank Statement, Utility / Telecoms bill.

Once we’ve received this, We will aim to get you registered with ourselves within 2 working days subject to all information needed being provided.

GMS1 Form

New Patient Registration Forms

Step 1 of 15

Basic Details

NHS Number Optional

What type of registration?

Permanent (GMS1) Optional

Temporary (GMS3) Optional

First Name

Surname

Previous Surname Optional

Email Optional

Date Of Birth

MM slash DD slash YYYY

Gender

Town and country of birth Optional

Current Address

Street Address Address Line 2 City County / State / Region ZIP / Postal Code Country

Home Telephone Optional

Mobile Telephone

Has this patient been registered in the NHS Before?

Yes Optional

No Optional

If no, Please enter date entered UK. Optional

Please help us trace your previous medical reocrds by providing the following information

Your previous address in the UK

Street Address Address Line 2 City County / State / Region ZIP / Postal Code Country

Name of previous GP Practice Optional

Address of previous GP Optional

If you are from abroad – Your first UK Address where you registered with a GP

Street Address Optional Address Line 2 Optional City Optional County / State / Region Optional ZIP / Postal Code Optional Country Optional

Your first UK Address where you registered with a GP

Date of arrival into UK Optional

MM slash DD slash YYYY

Were you ever registered with an armed forces GP?

UK Or Overseas Optional

Regular Optional

Reservist Optional

Veteran Optional

Family Member Optional

Address before enlisting?

Street Address Optional Address Line 2 Optional City Optional County / State / Region Optional ZIP / Postal Code Optional Country Optional

Service or Personnel Number Optional

Enlistment Date: Optional

Discharge Date Optional

If you need your doctor to dispense medicines and appliances

I live more than 1.6km in a straight line from the nearest chemist Optional

I would have serious difficulty in getting them from a chemist Optional

Next Of Kin

*Only add carers details if they give their consent to have these details stored on your medical record

Full Name:

Telephone Number

Relationship

Address

Street Address Optional Address Line 2 Optional City Optional County / State / Region Optional ZIP / Postal Code Optional Country Optional

If you do not know this please leave it blank, this is not a required field.

Previous Details

Name Of Previous GP Surgery Optional

Name Of Previous GP Optional

Background Information

Ethnicity

Religion Optional

Housing Optional

Employment Optional

Are you an overseas visitor?

Yes Optional

European Health Insurance Card Held Optional

Are you armed forces?

Military Veteran Optional

Currently Serving Optional

Family Member Optional

Communication Needs

What is your main spoken language

Do you need an interpreter?

Yes

Do you have any communication needs?

Yes

If yes, Which

Hearing Aid

Lip Reading

Large Print

Braille

British Sign Language

Makaton Sign Language

Do you have a learning disability?

Yes

Carer Details

*Only add carers details if they give their consent to have these details stored on your medical record

Are you a carer? Optional

Do you have a carer? Optional

Carers Name Optional

Phone Number Optional

Relationship To You Optional

Medical History

Do you have any underlying health/medical conditions?

Yes

Do any of your family members have history of conditions?

Yes

If so, Which conditions?

Asthma Optional

COPD Optional

High Blood Pressure Optional

Heart Disease Optional

Heart Failure Optional

Stroke Optional

Diabetes Optional

Kidney Optional

Cancer Optional

Depression Optional

Underactive Thyroid Optional

Epilepsy Optional

Other Optional

If so, Which conditions?

Asthma Optional

COPD Optional

High Blood Pressure Optional

Heart Disease Optional

Heart Failure Optional

Stroke Optional

Diabetes Optional

Kidney Optional

Cancer Optional

Depression Optional

Underactive Thyroid Optional

Epilepsy Optional

Other Optional

Do you have any allergies?

Yes

If so, Which?

Do you have any medications?

Yes

If so, Which?

Initial Alcohol Audit

How often do you have a drink containing alcohol?

How many standard drinks containing alcohol do you have on a typical day?

How often have you had 6 or more units (if female) or 8 or more units (if male), on a single occasion in the last year?

Total Number Of Points (This will automatically Update)

Please be aware if your score is greater than 5, We ask that you fill in the next set of questions that appear.

Alcohol AUDIT-C Questionnaire

What is the score from the Screening Questions (This will automatically update) Optional

How often in the last year have you found you were not able to stop drinking once you had started? Optional

How often in last year have you failed to do what was expected of you because of drinking? Optional

How often in the last year have you needed an alcoholic drink in the morning to get you going? Optional

How often in the last year have you had a feeling of guilt or regret after drinking? Optional

How often in the last year have you not been able to remember what happened when drinking the night before? Optional

Have you or someone else been injured as a result of your drinking? Optional

Has a relative/friend/health worker been concerned about your drinking or advised you to cut down? Optional

What is the score from the AUDIT-C Questionnaire (This will update automatically) Optional

Alcohol Audit Summary

Total Audit Score Optional

Thank you for completing this section, The score has different levels of categories and they are as follows: 1-7 = Lower Risk Drinker || 8-15 = Hazardous Alcohol Use || 16-19 = Harmful Alcohol Use || 20 or more = Possible Alcohol Dependence

Smoking Questionnaire

For more advice please see www.nhs.uk/smokefree

Do you smoke?

No Optional

Yes Optional

Ex-Smoker Optional

Do you use an e-cigarette?

No Optional

Yes Optional

Ex-User Optional

How many cigarettes did/do you smoke a day? Optional

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First Choice Optional

Second Choice Optional

Third Choice Optional

Height & Weight

Height Optional

Weight Optional

Women Only Section

Do you use any contraception?

Yes Optional

No Optional

Do you have a coil or implant in situ?

Yes Optional

No Optional

Are you currently pregnant or think you may be?

Yes Optional

No Optional

If yes, Expected due date Optional

Students Only

Students are at risk of certain infections including mumps, meningitis and sexually transmitted infections, as well as mental health issues including stress, anxiety and depression. Please see www.nhs.uk/Livewell/Studenthealth

I am less than 24 years old and have had two doses of the MMR Vaccination Optional

I am less than 25 years old and have had a Meningitis C Vaccination Optional

Final Section

If you would like your prescriptions to be sent electronically, please provide details of the pharmacy you would like to use Optional

Would you like to be involved in our Patient Participation Group?

Yes Optional

No Optional

We are committed to improving the services we provide. The Patient Participation Group is a mechanism for us to gain valuable feedback from our patients about their experiences, views and ideas for improving our services.

Blood Donor

I am already a blood donor Optional

I wish to be a blood donor Optional

I do not wish to be a blood donor Optional

Upload Documents

Upload Proof Of ID/Address Optional

Max. file size: 50 MB.

Untitled Optional