Register with us | Lennard Surgery

If you are human, leave this field blank.

Title *

First name *

Last name *

NHS Number

Date of Birth (DD/MM/YYYY) *

Address *

Address

City

State/Province

Zip/Postal

Country

Phone *

Place of birth *

Please provide your previous home address below: *

Please help us trace your medical records by providing your previous GP practice below: *

If you are from abroad, please let us know below your 1st UK address where registered with a GP:

If previously resident in the UK, date of leaving:

Date you first came to live in the UK:

If you are returning from the armed forces please provide your address before enlisting along with your service/personnel number

NHS Organ Donor registration. I want to register my details on the NHS Organ Donor Register as someone whose organ/tissue may be used for transplantation after my death. Please tick boxes that apply. For more info please visit www.uktransplant.org.uk

NHS Blood Donor Registration. I would like to join the NHS Blood Donor Register as someone who may be contacted and would be prepared to donate blood.

Tick here if you have given blood in the last 3 years

For more info please visit https://www.blood.co.uk/why-give-blood/

What is your first language

Do you require an interpreter? *

All conversations

Most conversations

None

What is your Ethnic Group

Please list any serious illnesses/operations/accidents/disabilities (any for any women pregnancy related problems) and the year they took place:

Please list any medications you are currently taking and the dosage: *

If you would like your prescriptions sent to a local pharmacy, please specify what pharmacy below:

Have you ever had an ADVERSE reaction to a medicine(s)

Yes

If yes please provide details below:

Have you ever had an ALLERGIC reaction to a medicine(s)

Yes

If yes please provide details below:

Next of Kin Name and relationship *

Next of Kin Address:

Next of Kin Contact Number: *

Do you give us your permission to: (tick as appropriate)

Discuss your medical conditions with next of kin

Contact your next of kin in an emergency

Do you smoke? (This includes vapes, e-cigarettes, pipe, tobacco)

Yes

If yes, How many cigarettes or ounces of tobacco do you smoke per week?

What is your height? In CM *

What is your weight? In KG *

Please state any family history of any serious illness, in particular heart disease, strokes, high blood pressure, diabetes or any inherited diseases:

If you are over the age of 16 please click here to complete the final part of registration form

If you are over the age of 16, please complete the Alcohol Consumption fields below:

How often do you have a drink containing alcohol?

How many units of alcohol do you drink on a typical day when you are drinking?

How often have tou had 6 or more units if female, or 8 or more units it male, in a single occasion in the last year?

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

How often during the last year have you failed to do what was normally expected from you because of drinking?

How often during the last year have you needed an alcoholic drinking in the morning to get yourself going after a heavy drinking session?

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

How often during the last year have you been unable to remember what happened the night before because you had been drinking?

Have your or somebody else been injured as a result of your drinking?

Has a relative or friend, doctor or other health worker been concerned about your drinking or suggested that you cut down

Date