The Manor Street Surgery

Manor Street, Berkhamsted, HP4 2DL

Current time is 02:12 - Sorry, we're closed

Telephone: 01442875935

Out of Hours: 111

Registration form – Adults

Registration Form - Adults

Step 1 of 9

Name*
Title First Name Surname Know As
Date of Birth*

Day
Month
Year
Place of Birth*
Gender*
- Male
- Female
- Other
Other - Please specify
NHS Number

If known please enter your NHS Number, this will make it easier for us to find your previous GP if you have one.

Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Phone
Can we contact you by text?*
- Yes
- No
Email
Can we contact you by Email?*
- Yes
- No
Previous Address in the UK*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Name and Address of Previous GP*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Nationality
Other - Please state
If you are from abroad which date did you come to live in the UK
Month
Day
Year
If you are returning from abroad and have previously been registered with the NHS
Date you left the UK:
DD slash MM slash YYYY
Date you returned to the UK:
DD slash MM slash YYYY

Emergency Contact Details
If we need to contact someone on your behalf in an emergency situation, who should this be?
Full Name Relationship to you Phone Number
Are they your next of kin?
- Yes
- No
Do you give us permission to contact them in an emergency?
- Yes
- No

Allergies
Do you have any allergies? Please list below. Press the + button to the right to add more.

Lifestyle
Height*
Weight
Blood Pressure
Smoking Status*
- Current Smoker
- Ex Smoker
- Never Smoked
Please state how much exercise and what type of exercise you do per week:*
- Light
- Moderate
- Avoid
Alcohol Consumption
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 you had 6 or more units if female, or 8 or more if male, on a single occasion in the last year?

Immunisation History
Please list any immunisations that you have had
Medical History
List any major illnesses
List any past operations
Please list any family history of illnesses
Please list your current medication
Sight
- Good
- Poor
- Registered Blind
Hearing
- Good
- Poor
- Partially Deaf
- Deaf
Accessible Information Standard
As part of the Accessible Information Standard we are looking to support people’s communication needs in the practice, please let us know if you would like any of our information provided in an alternative format, for example large print or easy read, or if you need help with communicating with us, for example because you use British Sign Language.
Over 75 years old?
The Department of Health has advised that all patients of 75years and older have a named and accountable GP to oversee their care. Please ask the name of the GP assigned to oversee your care. Please note this does not prevent you from seeing the GP of your choice.

Summary Care Record
Information for new patients: about your Summary Care Record

Dear patient,

If you are registered with a GP practice in England, you will already have a Summary Care Record (SCR), unless you have previously chosen not to have one. It will contain key information about the medicines you are taking, allergies you suffer from and any adverse reactions to medicines you have had in the past.

Information about your healthcare may not be routinely shared across different healthcare organisations and systems. You may need to be treated by health and care professionals who do not know your medical history. Essential details about your healthcare can be difficult to remember, particularly when you are unwell or have complex care needs.

Having a Summary Care Record can help by providing healthcare staff treating you with vital information from your health record. This will help the staff involved in your care make better and safer decisions about how best to treat you.

You have a choice

You have the choice of what information you would like to share and with whom. Authorised healthcare staff can only view your SCR with your permission. The information shared will solely be used for the benefit of your care.

Your options are outlined below; please indicate your choice on the form overleaf.
- Express consent for medication, allergies and adverse reactions only.
You wish to share information about medication, allergies for adverse reactions only.
- Express consent for medication, allergies, adverse reactions and additional information. You wish to share information about medication, allergies for adverse reactions and further medical information that includes: your illnesses and health problems, operations and vaccinations you have had in the past, how you would like to be treated (such as where you would prefer to receive care), what support you might need and who should be contacted for more information about you.
- Express dissent for Summary Care Record (opt out). Select this option, if you DO NOT want any information shared with other healthcare professionals involved in your care.
If you chose not to complete this consent form, a core Summary Care Record (SCR) will be created for you, which will contain only medications, allergies and adverse reactions.

Once you have completed the consent form, please return it to your GP practice. You are free to change your decision at any time by informing your GP practice.
Having read the above, please choose one of the options
Yes – I would like a Summary Care Record
- Express consent for medication, allergies and adverse reactions only.
- Express consent for medication, allergies, adverse reactions and additional information.
No – I would not like a Summary Care Record
- Express dissent for Summary Care Record (opt out).
Please tick to confirm you have selected an option*
- I have made my decision regarding the Summary Care Record

What happens to my information?
Personal and medical information about patients registered at this practice are primarily kept electronically, although some is kept in paper form. Some information will be sent to hospital consultants and other health professionals to whom you are referred by your GP in order to provide continued healthcare and obtain treatment for you. We sometimes use accredited suppliers for our communication with you, for example when we send recall letters for review clinics or medication reviews. All suppliers we use are checked carefully to ensure they comply with strict confidentiality protocols. To ensure the security of all patient information, all staff that has access to your records is covered by confidentiality clauses in their contracts and the Data Protection Act and the Freedom of Information Act. Our guiding principle is that we hold your records in strict confidence.
I certify that the information I have provided is correct and consent to my personal and medical information being used as stated above.
Signature*
Comments
This field is for validation purposes and should be left unchanged.

COVID-19 Vaccination Program

New Patients: How do I register?

How can I book an appointment?

Online Appointment Booking

Order your Prescriptions

Patient Participation Group

Friends & Family Test

Update your Details

Opening Times

Monday
07:00 until 20:00
For pre-booked telephone appointments only
Tuesday
08:00 until 18:30
Wednesday
08:00 until 18:30
Thursday
08:00 until 18:30
Friday
08:00 until 18:30
Saturday
CLOSED
Sunday
CLOSED

Useful Links

The Manor Street Surgery

Registration form – Adults

Registration Form - Adults

Step 1 of 9

If you are returning from abroad and have previously been registered with the NHS

Lifestyle

Alcohol Consumption

Immunisation History

Medical History

Over 75 years old?

Summary Care Record

What happens to my information?

Opening Times

Useful Links

Friends & Family Test

Update your Details