Adult New Patient Registration Form 16 years +

Fields marked "REQUIRED" are compulsory.. You should only send this form if you are sure that you are eligible to join this practice. Sending this form will NOT automatically register you with the surgery. Sending this form does NOT guarantee or even imply that you will be accepted onto the practice register.


Last Updated: 07/03/2023


What is Your Ethnic Group?

What is your ethichic group?

Choose one that best discribes your ethnic group or background.

  • White
  • Mixed/multiple ethnic groups
  • Asian/Asian British
  • Black/African/Caribbean/Black British
  • Other ethnic group
  • Prefer not to say

Depending on your answer the subsequent question will be on of the following






If you would like advice on managing a healthy weight, please contact  or reception who will be able to direct you to the most appropriate service.



If you would like help and advice on how to reduce your alcohol intake, please contact or ask at reception.


Smoking is the UK’s single greatest cause of preventable illness

Stopping smoking is not easy but it can be done, and there is now a comprehensive, NHS Smoking Cessation Service offering support and help to smokers wanting to stop, with cessation aids available on NHS prescription. 


If you would like help and advice on how to give up smoking, please contact or ask at reception. 



If YES to either of the above questions, please ensure you provide the practice with a copy of this so that this can be documented on your medical notes. 



If you opt out this will mean NHS Healthcare staff caring for you may

not be aware of your current medications, any allergies or reactions to previous medication.


The Care and Health Information Exchange (CHIE) is a secure system which shares key parts of your electronic record from GP surgeries, hospitals, community, mental health and social services. It allows health professionals across Hampshire and the Isle of Wight to provide safer and faster treatment for you and your family


Your information is also used to improve future care for you, your family and for other patients. This helps plan NHS services and supports medical research. To keep your information safe it is moved to a separate database called ‘Care and Health Information Analytics’ (CHIA) and changed so that it cannot be used to identify you. Your data is never shared for the benefit of commercial companies like drug manufacturers. People who analyse data on CHIA do not have access to CHIE, so cannot identify you. 


Patient Information Leaflet 




This leaflet explains why information is collected about you, the ways in which this information may be used and who will be collecting it. 


Data Share


NHS England aims to link information from all the different places where you receive care, such as hospital, community service and us your GP Surgery. This will allow them to share the care you received in one area with other providers of your medical care.


Information will be held in a secure environment called NHS Digital. The role of NHS Digital is also to ensure that high quality data is used appropriately to improve patient care.  NHS Digital has legal powers to collect and analyse data from all providers of NHS care. They are committed, and legally bound, to the very highest standards of privacy and confidentiality to ensure that your confidential information is protected at all times.  You can object to your data being used in this way – see below


This data can also be used, with permission, for research purposes. If you do not wish to share data for research, you can opt out:


• You can object to information containing data that identifies you from leaving the Practice. This will prevent identifiable information held in your record from being sent to the Summary Care Record secure environment. (Further information about the Summary Care Record is below   It will also prevent information about you leaving the practice to be stored in the local Care and Health Information Exchange – this is a local Hampshire service which stores your medical record and gives access to health care professionals who may need to treat you – such as the ambulance service, or the Emergency Department of our local hospitals

• You can also object to any information containing data that identifies you from leaving NHS Digital. This includes information from all places you receive NHS care, such as hospitals. If you object, confidential information will not leave NHS Digital and will not be used, except in very rare circumstances for example in the event of a public health emergency, for future service planning or for research


For more information visit:


The law requires Doctors to provide some very limited information about certain things. The law says, for example, that Doctors must provide information to local authorities about some infectious diseases, e.g. if you had food poisoning. Very rarely, Doctors may be required to disclose information in order to detect a serious crime. Likewise, a court order can require Doctors to disclose certain information during a court case.

We will never provide your information to anyone else without your explicit consent.  Records which you wish to share with other people such as solicitors will be provided to you so that you can review them before your share them.


Summary Care Record (SCR)

If you decide to have a SCR, it will contain important information about any medicines you are taking, allergies you suffer from and any bad reactions to medicines that you have had it will also include basic information about your current diagnoses. Giving healthcare staff access to this information can prevent mistakes being made when caring for you in an emergency or when your GP practice is closed. Your Summary Care Record will also include your name, address, date of birth and your unique NHS Number to help identify you correctly. If you and your GP decide to include more information it can be added, but only with your express permission. 

For more information:   Phone 0300 123 3020 or visit


Care and Health Information Exchange (CHIE) The HHR is an electronic summary record for people living in Hampshire, Portsmouth and Southampton. GP Surgeries, hospitals, social care and community care teams collect information about you and store it electronically on separate computer systems. The Care and Health Information Exchange stores summary information from these organisations in one place so that – with your consent – professionals can view it to deliver better care to you.  This record contains more information than the SCR, but is only available to organisations in Hampshire. 

For more information visit:


Benefits of sharing information

Sharing information can help improve understanding, responses to different treatments and potential solutions. Information will also help to:

• Provide better information to out of hours and emergency services 

• Prevent Prescribing of medication to which you may already have an allergy       

• Make more informed prescribing decisions about drugs and dosages Avoid unnecessary          duplication in prescribing

• Increase clinician confidence when providing care

• Results of investigations, such as X-rays and laboratory tests

• Reduce referrals, ambulance journey admissions, tests, time wastage and visits to healthcare premises

• Find out basic details about you, such as address and next of kind


Do I have a choice?

Yes. You have the right to prevent confidential information about you from being shared or used for any purpose other than providing your care, except in special circumstances. If you do not want information that identifies you to be shared outside this Practice, complete the sheet enclosed in this leaflet.  This will prevent your confidential information being used other than where necessary by law.


Objecting on behalf of others

If you are a carer and have a Lasting Power of Attorney for Health and Welfare then you can object on behalf of the patient who lacks capacity. If you do not hold a Lasting Power of Attorney then you can raise your specific concerns with the patient’s GP.


If you have parental responsibility and your child is not able to make an informed decision for themselves, then you can make a decision about information sharing on behalf of your child. If your child is competent then this must be their decision.


Do I need to do anything?

Note your decisions on the enclosed form and return to Reception. You can change your mind at any time, just complete another form.


Data Sharing




Data for research



If you wish to opt out, please visit           


ID Checked:


For Registration                      

Address Checked       


Online Services            


GP Advised                                                                                       …………………………………


New Patient Check Appt booked    Date ____/___/___



Is GP Appointment necessary for either repeat medication or urgent appointment?


YES/NO – If yes, Date ___/___/___


Appointment booked with ……………………………………..



Staff Name (PRINT): ……………………………..


Date: …………………………………



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