Adult Registration Questionnaire

Adult Registration Questionnaire

Please help us trace your previous medical records by providing the following information

If you are from abroad
If you are returning from the Armed Forces
If you need your doctor to dispense medicines and appliances*

* Not all doctors are authorised to dispense medicines

What is your ethnic group

Select the option that best describes your ethnic group or background from the options below

PATIENT DECLARATION for all patients who are not ordinarily resident in the UK

Anybody in England can register with a GP practice and receive free medical care from that practice. However, if you are not ‘ordinarily resident’ in the UK you may have to pay for NHS treatment outside of the GP practice. Being ordinarily resident broadly means living lawfully in the UK on a properly settled basis for the time being. In most cases, nationals of countries outside the European Economic Area must also have the status of ‘indefinite leave to remain’ in the UK. Some services, such as diagnostic tests of suspected infectious diseases and any treatment of those diseases are free of charge to all people, while some groups who are not ordinarily resident here are exempt from all treatment charges. More information on ordinary residence, exemptions and paying for NHS services can be found in the Visitor and Migrant patient leaflet, available from your GP practice.

You may be asked to provide proof of entitlement in order to receive free NHS treatment outside of the GP practice, otherwise you may be charged for your treatment. Even if you have to pay for a service, you will always be provided with any immediately necessary or urgent treatment, regardless of advance payment. The information you give on this form will be used to assist in identifying your chargeable status, and may be shared, including with NHS secondary care organisations (e.g. hospitals) and NHS Digital, for the purposes of validation, invoicing and cost recovery. You may be contacted on behalf of the NHS to confirm any details you have provided.


Complete this section if you live in another EEA country, or have moved to the UK to study or retire, or if you live in the UK but work in another EEA member state. Do not complete this section if you have an EHIC issued by the UK.

If you are visiting from another EEA country and do not hold a current EHIC (or Provisional Replacement Certificate (PRC))/S1, you may be billed for the cost of any treatment received outside of the GP practice, including at a hospital.

If yes, please enter details from your EHIC or PRC below:

How will your EHIC/PRC/S1 data be used? By using your EHIC or PRC for NHS treatment costs your EHIC or PRC data and GP appointment data will be shared with NHS secondary care (hospitals) and NHS Digital solely for the purposes of cost recovery. Your clinical data will not be shared in the cost recovery process. Your EHIC, PRC or S1 information will be shared with The Department for Work and Pensions for the purpose of recovering your NHS costs from your home country.

Additional Details about you
Carers Information

A carer is a friend / family member who gives their time to support a person in their home, to an extent that the person could not remain at home if this care was not being provided. A carer can receive Carers Allowance (but not a wage) and the care they are giving will significantly affect their own life.

Medical Details

Family History

Do you have Family History of any of the following:


Please tell us about your smoking habits

Please tell us about your alcohol consumption

1 unit = normal half pint beer (284 ml) 4% or Single shot spirit (25ml) 40%.

1.5 units = small glass of wine (125 ml) 12.5% or Alcopop (275 ml) 5.5%

2 units = strong half pint beer (284 ml) 6.5% or medium glass of wine (175ml) 12.5% or normal large bottle/can beer (440ml) 4.5%

3 units = strong bottle/can beer (440ml) 6.5% or bottle of wine (750ml) 12.5% or bottle spirits (750ml) 40% or large glass of wine (250ml) 12.5%


For women only

Next Of Kin / Emergency contact
Communication Preferences
Data Sharing

Summary Care Record (SCR)

As you are registering with this practice, we would like to recommend that you take advantage of the Summary Care Record (SCR). The Core SCR includes important information about your health: Medicines you are taking, allergies you suffer from and any bad reactions to medicines.

You can also choose to have additional information included in your SCR, which can improve the care you receive. This information 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.

You may need to be treated by health and care professionals outside of the practice who do not know your medical history. Having the additional information SCR can help the staff involved in your care access information more quickly, allowing them to make informed decisions about your healthcare. More information can be found by visiting

Medical Interoperability Gateway (MIG)

Whilst the SCR mentioned above shares a very small portion of your child’s medical record across the whole NHS, the MIG shares a much broader view of their records but only with local NHS providers – and only when you give explicit consent at the point of care.

For more information please visit

If you are a student - Meningitis ACWY Immunisation

NHS England strongly recommends anyone who is starting university aged between 18-24yrs have an ACWY booster if you haven’t already done so.

Donor Registration Choices

On 20 May 2020, the law around organ donation in England was changed to allow more people to save more lives

Now that the law has changed, it will be considered that you agree to become an organ donor when you die, if:

• you are over 18;

• you have not opted out;

• you are not in an excluded group.

For more information please visit

Online Patient Access

Once your application to join our practice has been accepted you’ll be able to order your repeat medications and book appointments. This service is known as Systmonline. To register visit or ask reception for an application form. You need to bring the completed form to reception then you’ll be given a username and password so you can create the online account.

Each individual will need their own username and password.

You will be able to book an on-line TELEPHONE consultation, view and order your medication, view your test results, send the surgery a message.. You can also view your Summary Care Record unless you’ve chosen not to have one. You will also be able to see any allergies recorded, vaccinations, previous illnesses, hospital discharge summaries, appointment letters and referral letters

Ordering Medication on-line

Items that appear on your tick slip and medications that you have had from the surgery in the past will be listed on Systmonline.

Change of Contact Details

You can update us with your new address, telephone number, e-mail online. You can also consent to receiving text message reminders for things like appointments

How To Order Your Repeat Medication

For safety reasons, we do not take prescription requests over the telephone

There are a number of ways you can order your medication:-

On-line via Systmonline (you will need a username and password)

e-mail –

Post your request to Springfields Medical Centre, Legh Street, Warrington WA1 1UG

Complete a prescription request form at the surgery

It takes 48 hours to process your medication. If we receive your request before 4 pm it will be ready within 48 hours after 4 pm.

Your GP will routinely review your medication and may ask you to arrange a review with our Clinical Pharmacist.

If you are due a medication review or health check and fail to attend, we reserve the right to reduce your medication until you have had your review.

Nominated Pharmacy

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.

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