Family Doctor Service Registration – Adult

Poplar Primary Care Centre

58 Poplar Road, Kings Heath, B14 7AG

Tel: 0121 465 8314

Patients Details:
Mr Mrs Miss Ms Surname:
Date of Birth: _ _ / _ _ / _ _ _ _ First Names:
NHS Number: _ _ _ / _ _ _ / _ _ _ _ Previous Surname(s):
Male Female Town&Country of Birth:
Home Address:
Postcode: Telephone number:

Please help us trace your previous medical records by providing the following information:
Your Previous address in UK: Name of Previous Doctor while at that address:

Address of Previous Doctor:

If you are from abroad:

Your first UK address where registered with a GP:

If previously resident in UK date of leaving: Date you first came to live in UK:
If you are returning from the Armed Forces:
Address before enlisting:

Service/personnel number: Enlistment Date:

Signature of Patient Signature on behalf of patient

Date:______/______/_______ Signature:

NHS Organ Donor Registration

I want to register on the NHS Organ Donor Register as someone whose organs/tissue may be used for transplantation after my death. Please tick the
boxes that apply:
Any of my organs and tissue or:

Kidneys Heart Liver Corneas Lungs Pancreas

Signature confirming my agreement to organ/ tissue donation: Date: _ _ / _ _ / _ _ _ _

For more information, please ask at reception for an information leaflet, or visit the website: www.uktransplant.org.uk or call 0845 60 60 400

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

Signature confirming consent to inclusion on the NHS Blood donor register: Date: _ _ / _ _ / _ _ _ _

For more information please ask for the leaflet on joining the NHS Blood Donor Register.
My preferred address for donation is: (only if different from above, e.g. your place of work)

Postcode:

Please also complete the reverse side of this form

Next of Kin: (name and relationship): Next of kin contact number:

Do you have / Have you ever had any of the following medical conditions? Please tick any / all that apply:

Asthma Emphysema / COPD Epilepsy Thyroid Gland disorders

Heart Disease Stroke / Mini Stroke Diabetes High Blood Pressure

If you have ticked yes to any of these, please book an appointment to see our Practice Nurse for a routine medical.

Do you have any other current medical problems? Do you consider yourself to have a life long medical
condition?
No Yes

Are you on any REPEAT PRESCRIPTIONS from your previous doctor? YES NO

If you have ticked YES then please book an appointment to see one of the doctors, to set up your repeat prescriptions.
Please bring all of your medicines / repeat prescription order form with you to this appointment.

Do you have any allergies to medicines? Penicillin Other medicines (please specify)

Please nominate a pharmacy to send your prescriptions electronically to:

Twilight Pharmacy (opposite surgery) Lloyds, High St, Kings Heath Boots, High St, Kings Heath

Other: __________________________________________

Do you smoke? Yes, How many cigarettes / day:___________

No, never smoked Gave up more than 5 years ago Gave up less than 5 years ago
How often do you have a drink that Never Monthly or less 2-4 times per 2-3 times per 4+ times per
contains alcohol? month week week
How many standard alcoholic drinks* do
you have on a typical day when you are 1-2 3-4 5-6 7-8 10+
drinking
How often do you have 6 or more Never Less than Monthly weekly daily / most
standard drinks on one occasion monthly days
* One standard drink / unit is the equivalent of ½ pint of normal strength beer, a small glass of wine, or a pub measure of spirits.

What ethnic group do you consider yourself to be part of? What is your first language? Your faith?

This information helps us to plan services for the future. You are not obliged to answer these questions.

Are you?
Married Widowed Single living with male partner Single living with female partner Single

Female Patients only:

Date of last cervical smear: ______________________

Are you currently using any contraception?

Pill Injection Implant Coil/Mirena Other

Thank you for completing this form, which provides us with useful information which helps us to plan our services better.
We are not able to register patients until we have collected this information.

Please remember to book an appointment with our practice pharmacist if you

are taking any repeat medications, and/or the nurse if you have any of the
medical conditions listed above.