New Patient Registration

It is very important that we can contact you. It is your responsibility to keep us updated with any changes to your telephone number, email & postal address. We may contact you with appointment details, test results or health campaigns. If you do not consent to be contacted by text message or email please let us know.

Title

First Name

Surname

NHS numberIt is always helpful to have the NHS number. You can either ask your current NHS services provider for this information or it can be found on your NHS app or simply login to www.nhs.uk/nhs-services/online-services/find-nhs-number

Postal Address including postcode

Gender

Date of Birth

Home Telephone Number

Next of Kin: Name / Tel number and relationship

What is your main spoken language? It will be helpful for us to know if you cannot communicate in English. We have GPs speaking variety languages and we may be able to accommodate GP speaking your language or arrange for interpreter when as and when required

Do you need and interpreter?

Do you have any communication difficulties?

Are you a carer?Being registered as an unpaid carer enables us to offer you access to Carers Trust Clinics that are run every Thursday afternoon at the practice

Do you have a carer?Can you please provide Name, Telephone Number and Relationship of the carer

Armed Forces

Etnicity

Previous GPIf you are foreign national that have never been registered with a GP please state date of entry into the UK

NHS App – online access to medical records You consent to being responsible for the security of the information that I see or download. If you choose to share my information with anyone else, this is at your own risk. You will contact the practice as soon as possible if you suspect that your account has been accessed by someone without my agreement. If you see information in your record that it not about you, or is inaccurate you will log out immediately and contact the practice as soon as possible. Additionally it is essential to be aware of: Forgotten history There may be something you have forgotten about in your record that you might find upsetting. Abnormal results or bad news If your GP has given you access to test results or letters, you may see something that you find upsetting to you. This may occur before you have spoken to your doctor or while the surgery is closed and you cannot contact them. Choosing to share your information with someone It’s up to you whether or not you share your information with others – perhaps family members or carers. It’s your choice, but also your responsibility to keep the information safe and secure. Coercion If you think you may be pressured into revealing details from your patient record to someone else against your will, it is best that you do not register for access at this time. Misunderstood information Your medical record is designed to be used by clinical professionals to ensure that you receive the best possible care. Some of the information within your medical record may be highly technical, written by specialists and not easily understood. If you require further clarification, please contact the surgery for a clearer explanation. Information about someone else If you spot something in the record that is not about you or notice any other errors, please log out of the system immediately and contact the practice as soon as possible

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.

I consent to my information being used for the purposes described above and wish to submit this online form to Willenhall Oak Medical Centre • 70 Remembrance Road, Coventry, CV3 3DP .

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.