Patient Registration Form Step 1 of 8 - Contact Information 0% Name* First Last Date of Birth* DD slash MM slash YYYY Gender* Male Female Prefer not to say NationalityEthnicityOccupationHome Number*Mobile Number*Email* Address (Permanent or Temporary)*Please fill in all address fields below. Street Address City Postcode / Zip AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country How did you hear about the practice?* Website Friend / Referral Social Media Advertising Other May we contact you by email with information that may be of interest to you?*For example Newsletters, Medical News and additional updates from our team of medical professionals. Yes No Nominated ContactsDo you agree to the processing and sharing of Personal Data about the progress of your treatment with your nominated contact(s)? Yes No Nominated Contact Name First Last Nominated Contact Phone NumberRelationship to Nominated ContactAdd a second Nominated Contact Yes No Second Nominated Contact Name First Last Second Nominated Contact Phone NumberRelationship to Second Nominated ContactNominated Contact Name*I consent to The London General Practice (TLGP) processing and sharing Personal Data about the progress of my treatment with my nominated contact(s). First Date MM slash DD slash YYYY Other GP / Doctor / ConsultantPlease let us know if you would like any other GP/Doctor/Consultant notified of this and/or any future consultations NHS Private Not Applicable Other GP / Doctor / Consultant Contact Name First Last Other GP / Doctor / Consultant Address Street Address City County / State / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Patient Signature*I consent to The London General Practice (TLGP) to share my medical information with my GP/Doctor/Consultant Signature Date MM slash DD slash YYYY Do you require a chaperone for this consultation?Please advise us before any consultation whether you wish to have a chaperone. It is our policy to provide a chaperone for all intimate examinations. It is also our policy that all paediatric examinations must be carried out in the presence of a parent or guardian. Yes No Your HealthHow is your health at present? Is there anything specific you would like to discuss with the doctor today?Do you have any significant past medical history?(e.g. head and neck problem, eyes, ears, nose, throat, heart pain, palpitations, pneumonia, asthma, kidney stones, bones/joints, back, for example pain, slipped disc, abdominal pain, IBS, liver, piles, constipation, epilepsy, tumours, neurological problems, prostate, urinary flow, diabetes, thyroid problems) Yes No Past Medical DetailsPlease give detailsHave you had any operations or been admitted to hospital? Yes No Previous operations or hospital admission detailsPlease give detailsHave you had any recent investigations?(e.g. blood tests, scans) Yes No Recent Investigation DetailsPlease give detailsAre you currently taking any medication? Yes No Current Medication Details(drug name and dosage)Do you have any known allergies?(all including medication/ other) Yes No Allergy DetailsPlease give details Do you exercise? Yes No Exercise DetailsPlease give details on type of exercise and frequency per weekDo you smoke? Yes No If Yes, how many do you smoke per day?If you have stopped smoking, when did you stop?How many did you smoke per day?Do you drink alcohol? Yes No How often do you drink alcohol?(times per week, month or year)How many units do you consume?small glass wine (125ml = 1.5 units); normal strength beer (1/3 pint = 1 unit); small measure spirit (25ml = 1unit) Do you have any problems with your periods?(e.g. heavy periods) Yes No Please give details of period problemsDate of last period?(if relevant) MM slash DD slash YYYY Could you be pregnant? Yes No Do you have any problems with your breasts?(e.g. lumps) Yes No If Yes, please give details of breast problemsHave you had a mammogram before? Yes No Last mammogram results?Date of Last mammogram results MM slash DD slash YYYY Do you currently use contraception? Yes No If Yes, please give details of contraceptions used Is there a history of any of the following (listed below) or other conditions in your family?*Tuberculosis, epilepsy, diabetes, heart disease, high blood pressure, glaucoma, asthma, cancer or any other. Yes No Please tick all family members with medical conditions Father Mother Partner Children Brother(s) Sister(s) Grandfather (paternal) Grandmother (paternal) Grandfather (maternal) Grandmother (maternal) Uncle(s) Aunt(s) Cousin(s) Father's AgeFather's ConditionCause of Father's Death (if applicable)Mother's AgeMother's ConditionCause of Mother's Death (if applicable)Partner's AgePartner's ConditionCause of Partner's Death (if applicable)Children's AgeChildren's ConditionCause of Children's Death (if applicable)Brother(s) AgeBrother(s) ConditionCause of Brother(s) Death (if applicable)Sister(s) AgeSister(s) ConditionCause of Sister(s) Death (if applicable)Grandfather (paternal) AgeGrandfather (paternal) ConditionCause of Grandfather (paternal) Death (if applicable)Grandmother (paternal) AgeGrandmother (paternal) ConditionCause of Grandmother (paternal) Death (if applicable)Grandfather (maternal) AgeGrandfather (maternal) ConditionCause of Grandfather (maternal) Death (if applicable)Grandmother (maternal) AgeGrandmother (maternal) ConditionCause of Grandmother (maternal) Death (if applicable)Uncle(s) AgeUncle(s) ConditionUncle(s) Death (if applicable)Aunt(s) AgeAunt(s) ConditionAunt(s) Death (if applicable)Cousin(s) AgeCousin(s) ConditionCousin(s) Death (if applicable) Previous COVID Infection? Yes No If yes, when?Do you have any long COVID Symptoms – please detail if any.Did you have any complications: - please detail if any.What was the date of your last vaccination? Day Month Year In this section "Data Protection Laws" means the Data Protection Act 2018, the Privacy and Electronic Communications (EC Directive) Regulations 2003 and any other Applicable Law relating to the processing, privacy or use of Personal Data; and "Personal Data" shall have the meaning given to it in the relevant "Applicable Law" with Personal Data including sensitive Personal Data and special categories of Personal Data. "Applicable Law" shall mean all applicable statutes, regulations, orders, regulatory requirements, by laws, ordinances, rules, subordinate legislation and other laws, including any judicial or administrative interpretation of them, in force from time to time in any applicable jurisdiction. The London General Practice (TLGP) is committed to protecting and respecting patient privacy and to complying with Data Protection Laws and medical confidentiality guidelines. We have procedures in place to ensure that your information is kept safe, and that your Personal Data are kept confidential at all times. Please tick each of the boxes below if you agree to TLGP processing and sharing your Personal Data (whether obtained by TLGP and whether obtained at TLGP or another hospital or surgery) in the way described: Please note that you can opt out at any time from any of the data processing and data sharing initiatives described below (although this will not affect the lawfulness of any processing of your Personal Data up to that point). If you change your mind at a later date please contact us here: info@thelondongeneralpractice.comInformation about TLGP From time to time TLGP would like to inform you about new treatments, facilities, services, and offers. If you want to receive information about products and services from TLGP, please let us know by ticking the relevant boxes below:Post* Yes No Telephone* Yes No Email* Yes No Insurance Companies/Embassies/GP/Consultant and/or Sponsor*In ticking this box, you agree to the processing and sharing of Personal Data about the progress of your treatment with your health insurance company, embassies, GP, consultant and/or sponsor. Yes No Consent to Leave Voicemail Messages Containing Medical Information*By ticking the box below, you consent to TLGP leaving voicemails containing your medical information on the phone number(s) listed on this Patient Registration Form. This information may include, but is not limited to, demographic information (patient name, date of birth, address, etc.), billing information, and medical information (appointment dates, diagnosis, medications, test results, etc.) Please tick this box if you wish for TLGP’s staff to leave voicemails containing your medical information: Yes No Consent to Send Un-Encrypted Emails*For your security emails sent out by TLGP containing confidential patient data (e.g. clinical information) are encrypted using Egress Software to ensure information can be exchanged securely. By ticking the box below, you consent to TLGP contacting you by un-encrypted email. Information included in these emails may include, but is not limited to, demographic information (patient name, date of birth, address, etc.), billing information, and medical information (appointment dates, diagnosis, medications, test results, etc.). In ticking this box you are accepting the risks associated with receiving unencrypted results via email: Yes No Data Protection - Agreement and Declaration*Data Protection - Agreement and Declaration 1: You may be receiving care from other people as well as employees of TLGP. So that we all work together for your benefit, TLGP may need to share some information about you with those people or organisations, and they may wish to send your information to companies/individuals outside the European Economic Area to support subsequent care. Medical information will be disclosed to those involved with your treatment or care at TLGP and, if applicable, to any person or organisation or their agents or service providers within and outside the European Economic Area to carry out Service (which may include transcription of medical notes) and support your subsequent or ongoing care. 2: TLGP will share your (or where applicable, your Guarantor or Sponsor's) non-medical information in relation to billing, processing, payment or collection of accounts, or credit referencing information. This extends to any person or organisation they may involve in order to achieve this. TLGP will employ appropriate measures to protect your personal data where this is the case. 3: TLGP has regulatory and/or compliance obligations to share certain clinical data with various governmental and regulatory bodies (for example the Care Quality Commission). This may include any personally identifiable clinical information, including your NHS patient identification number or its equivalent. Agreement, Declaration and Consent I acknowledge and understand I confirm that I have read, understood and accept the terms and conditions outlined above. I understand that I am personally responsible for any costs associated with my procedure if these costs are not covered by medical insurance, insurer or other third party such as a guarantor. I undertake to settle all personal expenses, cost of treatment at the time of my departure or upon request. I give permission to TLGP or any other health care professional involved in my care, to access health information about me that is relevant to my treatment, which may be held by TLGP, other health professionals or health organisations. I confirm that the information I have provided in this registration form is a true reflection of my current health and past medical history. First Last Date* MM slash DD slash YYYY If you are not the patient please state relationship to the patient
