For office use only. Chronic Disease Check:
As someone wishing to register with the Practice please answer the following questions as accurately and completely as you can. It is important that we have as much information as possible. Thank you.
Home tel no: ………………………………. Mobile tel no: ……………………… Preferred method of contact: ………………………………………………………. Occupation …………………………Disability status ……………………………. The Practice uses a reminder system for appointments. A message will be sent to your mobile phone when you book an appointment at the surgery and a reminder will be sent 48 hours before your appointment time. Please indicate here if you do not wish to use this service. ….…… Personal Medical History Please list any chronic diseases you suffer from, eg Diabetes, Asthma, Heart Disease, High Blood Pressure, Epilepsy, COPD (Chronic bronchitis/emphysema), Hypothyroidism (take Levothyroxine), Stroke: Chronic
Have you had any investigations within the last 3 months? If yes please list: If possible please attach a list of repeat prescriptions that you currently take. If not please list all medications you take below. It is important that you tell us about these.
For office use only. Chronic Disease Check:
Please give the date of your last flu vaccine: Are you allergic to any medication? Eg penicillin Yes/No Please list the medication you have had an allergic reaction to below
Please answer the following questions which will be treated as confidential. We are unable to process your application without these answers: Do you smoke:
If so how many a day?: If no have you ever?: How much alcohol do you drink each week? 1 unit is ½ pint beer, 1 small glass of wine For female patients: Please can you provide the date of your last smear and if possible the result of that smear: Last smear date
Ethnic origin
We are now required by the Government to collect this information on all our patients. Please can you indicate the ethnic category you belong to below:
Bangladesh/British Bangladesh Caribbean
Please can you also state your main spoken language ………………………. You will be able to book appointments and order your prescriptions online. Please indicate here if you wish to register for this Yes/No From time to time to provide you with the best care possible we may need to share your health information electronically with other Health Care Professionals. Please indicate here if you do not wish your information to be shared in this way.
Thank you for your time. The GP’s will now consider your application. Please contact the surgery in 7 days regarding your application. In normal circumstances we will only write to patients whose application has been refused giving the reason for that refusal.
Comprehensive Family Dentistry Mark A. Gustus, D.D.S. Please comPlete the following confidential information I N S U R A N C E Date _________________________________________________________ PRIMARy CARRIER Insurance Co. __________________________________Name________________________________________________________Employee Name _______________________________Address ________________