New Patient Health Questionnaire
New Patient Information
Please make sure both the PURPLE REGISTRATION FORM and the NEW PATIENT HEALTH QUESTIONNAIRE are both FULLY completed and SIGNED where appropriate.
We require:
If you are from overseas you are required to fill in the additional information on the back of the purple registration form.
If you require medication prescribing, please provide us with a copy of right-side of repeat prescription or labelled boxes for them to be added during the registration process.
Many thanks,
Kingsfold Medical Centre
New Patient Health Questionnaire
Alcohol
(1 unit = half pint of beer, 1 glass of wine or a pub measure of spirits)
Present or significant health problems
Medication
Allergies
Family History
Carers
Military Veteran
Contact from the Practice
Patient Ethnic Origin Questionnaire
This section is to be completed for Care Home Residents ONLY
Medication.
Please include Name and Quantity
Privacy Protection
Information submitted through secure forms is used only for the purposes of processing your request. We may
be in touch with you in relation to the information submitted.
All Information submitted through secure forms is secured with a private key and is accessed over a secure
connection by nominated staff. We have a strict confidentiality policy.
This information is not shared with any third party organisations.
This information is retained for up to 28 days.
Learn more about our Privacy Policy and
Terms of Use.
Should you have any concerns about sending your personal details using the web,
please use one of the alternative methods offered by our organisation.