The Swan Practice
Online Registration

Please fill in your details and click Submit when complete.

Please only complete this registration form once. If you have previously submitted this form
at any time please do not do so again unless advised by the Medical Centre to do so.
If you are unsure of your registration status, you can contact the practice who will be able to confirm this for you.

The information you are submitting will be sent encrypted to the medical practice over the Internet, which still isn't 100% secure.
If you are worried about this you can instead obtain a form from the medical practice that can be filled in and delivered by hand.
* = Compulsory.

Have you ever registered with this practice before?	Yes   No
* Title:	Mr   Mrs   Miss   Ms
* Surname (Family name):
* First name(s):
Preferred (calling) name: (if different from your first name)
Previous surname(s): (if you've changed your surname)
* Date of birth:	Day 01 02 03 04 05 06 07 08 09 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 Month January February March April May June July August September October November December Year 2024 2023 2022 2021 2020 2019 2018 2017 2016 2015 2014 2013 2012 2011 2010 2009 2008 2007 2006 2005 2004 2003 2002 2001 2000 1999 1998 1997 1996 1995 1994 1993 1992 1991 1990 1989 1988 1987 1986 1985 1984 1983 1982 1981 1980 1979 1978 1977 1976 1975 1974 1973 1972 1971 1970 1969 1968 1967 1966 1965 1964 1963 1962 1961 1960 1959 1958 1957 1956 1955 1954 1953 1952 1951 1950 1949 1948 1947 1946 1945 1944 1943 1942 1941 1940 1939 1938 1937 1936 1935 1934 1933 1932 1931 1930 1929 1928 1927 1926 1925 1924 1923 1922 1921 1920 1919 1918 1917 1916
NHS No. (if known):
* Gender:	Male   Female
* Town and country of birth:
Marital status:
Please enter your local new ADDRESS below:
Student Accommodation: (if applicable)	Please select... 28 Nelson Street 1 Norton's Place 2 Norton's Place 3 Norton's Place 4 Norton's Place 5 Norton's Place 6 Norton's Place 7 Norton's Place 8 Norton's Place Hailsham House Hutber House Sunley Building Beloff House Bishops Court Mitre Court Bateman House Caine House Harris House Paulley House 25 London Road 1 Shetland 3 Shetland 5 Shetland 7 Shetland 25 Shetland 27 Shetland 20 Whitehead Way 22 Whitehead Way 24 Whitehead Way 26 Whitehead Way 28 Whitehead Way 30 Whitehead Way 32 Whitehead Way 36 Whitehead Way 37 Whitehead Way 38 Whitehead Way 44 Whitehead Way 46 Whitehead Way 56 Whitehead Way 7 Teeswater 9 Teeswater 11 Teeswater 15 Teeswater 17 Teeswater 19 Teeswater 21 Teeswater 23 Teeswater
Hall/Block/Flat/Room: (if applicable)
* Number and Street Address:
Locality/Area:
* Town:
* Postcode:
UK Mobile telephone number:
* Email address:
* Confirm Email address:
We would like to be able to contact you with email and SMS/text messages. * May we contact you with email? Yes   No * May we contact you with SMS/text? Yes   No
Please help us trace your medical records by selecting if you are from the UK or International (Part 1) and then filling in the next section (Part 2)
* Part 1. Select if you are from UK or abroad:	from UK International
Part 2: Fill in if you come from the UK * Previous Address in UK: (i.e. the address your current GP will have for you) * Town: * Postcode: * Name of Doctor or Surgery when at that address: * Address of Doctor or Surgery: Postcode:
Part 2: Fill in if you come from abroad (international student) * Date when you arrived in UK: Day 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 Month January February March April May June July August September October November December Year 2024 2023 2022 2021 2020 2019 2018 2017 2016 2015 2014 2013 2012 2011 2010 2009 2008 2007 2006 2005 2004 2003 2002 2001 2000 1999 1998 1997 1996 1995 1994 1993 1992 1991 1990 1989 1988 1987 1986 1985 1984 1983 1982 1981 1980 1979 1978 1977 1976 1975 1974 1973 1972 1971 1970 1969 1968 1967 1966 1965 1964 1963 1962 1961 1960 1959 1958 1957 1956 1955 1954 1953 1952 1951 1950 1949 1948 1947 1946 1945 1944 1943 1942 1941 1940 1939 1938 1937 1936 1935 1934 1933 1932 1931 1930 1929 1928 1927 1926 1925 1924 1923 1922 1921 1920 1919 1918 1917 1916 1915 1914 1913 1912 1911 1910 1909 1908 1907 1906 1905 1904 1903 1902 1901 1900 How many months will you stay in the UK? Have you lived or studied in the UK before? Yes    No Your UK address where registered with a GP: (only if you have previously registered with a GP) Town: Postcode: If a previous resident in UK, date of leaving: Day 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 Month January February March April May June July August September October November December Year 2024 2023 2022 2021 2020 2019 2018 2017 2016 2015 2014 2013 2012 2011 2010 2009 2008 2007 2006 2005 2004 2003 2002 2001 2000 1999 1998 1997 1996 1995 1994 1993 1992 1991 1990 1989 1988 1987 1986 1985 1984 1983 1982 1981 1980 1979 1978 1977 1976 1975 1974 1973 1972 1971 1970 1969 1968 1967 1966 1965 1964 1963 1962 1961 1960 1959 1958 1957 1956 1955 1954 1953 1952 1951 1950 1949 1948 1947 1946 1945 1944 1943 1942 1941 1940 1939 1938 1937 1936 1935 1934 1933 1932 1931 1930 1929 1928 1927 1926 1925 1924 1923 1922 1921 1920 1919 1918 1917 1916 1915 1914 1913 1912 1911 1910 1909 1908 1907 1906 1905 1904 1903 1902 1901 1900 Supplementary Questions: 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 of 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, exemption 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 purpose of validation, invoicing and cost recovery. You may be contacted on behalf of the NHS to confirm any details you have provided. Please select one of the following options: More information... I understand that I may need to pay for NHS treatment outside of the GP practice I understand that I have a valid exemption for paying for NHS treatment outside of the GP Practice. I can provide documents to support this when requested This includes for example, an EHIC, or payment of the Immigratin Health Charge ("the Surcharge"), when accompanied by a valid visa. I do not know my chargeable status Complete the following section if you come from another EEA country: Do not complete this section if you have an EHIC issued by the UK. Do you have a non-UK EHIC or PRC? Yes   No Please enter details from your EHIC or PRC below: Country code: 3 Family Name: 4 Given names: 5 Date of Birth: (dd/mm/yyyy) 6 Personal Identification Number: 7 Identification Number of the Institution: 8 Identification number of the card: 9 Epiry Date: (dd/mm/yyyy) PRC validity period From: (dd/mm/yyyy) PRC validity period To: (dd/mm/yyyy) Tick here if you have an S1 (e.g. if you are retiring to the UK or you have been posted here by your employer for work or you live in the UK but work in another EEA member state). Please give your S1 form to the practice staff. More information... How will your EHIC/PRC/S1 date 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 purpose 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.
* Signature:	Clear
Health Questionnaire
Nationality:     * Ethnic origin: Please select... British Irish Irish Traveller Traveller Gypsy/Romany Polish Any other White (please specify) White and Black Caribbean White and Black African White and Asian Any other Mixed (please specify) Indian Pakistani Bangladeshi Any other Asian (please specify) Caribbean African Somali Nigerian Any other Black (please specify) Chinese Filipino Any other ethnic group (please specify) Prefer not to say Other: * Main language: Please select... English - Abkhazian Afar Afrikaans Akan Albanian American Sign language Amharic Arabic Aragonese Armenian Assamese Australian sign language Avaric Avestan Aymara Azerbaijani Bambara Bamoun Bamun Bashkir Basque Belarusian Bengali Bihari Bislama Bokmal, Norwegian Bosnian Braille British sign language Bulgarian Burmese Cantonese Catalan Central Khmer Chamorro Chechen Chichewa Chinese Church Slavic Chuvash Cornish Corsican Cree Croatian Czech Danish Dari Divehi Dutch Dzongkha English Esperanto Estonian Ethiopian Ewe Faeroese Faroese Farsi Fijian Filipino Finnish Flemish French French Creole Frisian Fulah Gaelic Galician Georgian German Greek Greenlandic Guarani Gujarati Haitian Hakka Hausa Hebrew Herero Hindi Hindko Hiri Motu Hungarian Iba Iban Icelandic Ido Igbo Indonesian Interlingua Interlingue Inuktitut Inupiaq Irish Italian Japanese Javanese Kalaallisut Kannada Kanuri Kashmiri Kazakh Kikuyu Kinyarwanda Kirghiz Komi Kongo Konkani Korean Kuanyama Kurdish Kutchi Lao Latin Latvian Limburgan Lingala Lithuanian Luba-Katanga Luganda Luxembourgish Macedonian Main spoken language NOS Makaton sign language Malagasy Malay Malayalam Maltese Mandarin Manx Maori Marathi Marshallese Moldavian Mongolian Nauru Navajo Ndebele Ndonga Nepali Northern Sami Norwegian Norwegian Nynorsk Occitan Ojibwa Oriya Oromo Ossetian Pali Panjabi Pashto Patois Persian Polish Portuguese Punjabi Pushto Quechua Romanian Romansh Rundi Russian Samoan Sango Sanskrit Sardinian Serbian Serbo-croatian Shona Sichuan Yi Sindhi Sinhala Sinhalese Slovak Slovenian Somali Sorani Kurdish Southern Sotho Spanish Sundanese Swahili Swati Swedish Sylheti Tagalog Tahitian Tajik Tamil Tatar Telugu Tetum Thai Tsonga Tswana Turkish Turkmen Twi Uighur Ukrainian Urdu Uzbek Venda Vietnamese Volapuk Walloon Welsh Western Frisian Wolof Xhosa Yiddish Yoruba Zhuang Zulu Need interpreter: Yes   No * Have you lived in another country for 6+ months in the last year? Yes   No If yes, which country:
IMMUNISATIONS - essential information required You are strongly advised to ensure you are fully immunised to UK Department of Health standards. There is an increased risk of Meningitis, Measles, Mumps and Rubella due to the large numbers of students in the close confines of a university campus, therefore it is important that you are vaccinated to protect both yourself and others. Please indicate if you have/have not had the following: * Meningitis ACWY vaccine: Yes, date: Yes, but unsure of date No * 1st MMR (measles, mumps, rubella) vaccine: Yes, date: Yes, but unsure of date No * 2nd MMR (measles, mumps, rubella) vaccine: Yes, date: Yes, but unsure of date No
Have you been diagnosed with any of the following CONDITIONS?
Asthma: High blood pressure:   Cancer: High cholesterol: COPD: Osteoporosis: Chronic Kidney Disease: Stroke: Diabetes: Mental health problems: Epilepsy: Underactive thyroid:  Heart attack/disease: Circulation problems:
* Have you had/do you suffer from any serious ILLNESS?Yes   No  * Please state if you have or have had any other significant medical condition. For each item please tell us the year the event happened or when the problem started:
Have you had any significant INJURIES or OPERATIONS?Yes   No  * Please state if you have or have had any significant injuries or operations . For each item please tell us the year the event happened:
Do you have any DISABILITY/COMMUNICATION needs?Yes   No  * Please state any disability or communication needs:
* Do you suffer from any ALLERGIES?Yes   No  * Please state any allergies you have:
Do you take any prescribed MEDICATION at present?Yes   No  (including the pill and depo-injections) * Please list any prescribed medicines you use: Patients are required to see a doctor for the first time a prescription for long-term medication is requested from us. Make an appointment BEFORE your next repeat prescription is due. Thereafter, if it is appropriate for you to receive repeat prescriptions the following points should be noted;   1. Request your repeat medication at least 1-2 weeks before you run out (in case an appointment is required) 2. It takes a maximum of 2 working days for repeat prescriptions to be processed 3. You will be required to see a doctor from time to time to review your condition and medication
Do any of your close RELATIVES suffer from any of the following medical problems?
Heart attack:   Angina:   Asthma:   Diabetes:   Stroke:   Cancer:   Any inherited disease:
Height: cm   ft/inch Weight: kg   stone/lbs
* Do you SMOKE? Yes   Never    Used to smoke (not now)
When did you start?       When did you stop?
* Amount you smoke per day:   Please select... Less than 1 per day 1 to 9 per day 10 to 19 per day 20 to 39 per day 40 or more per day For help with stopping smoking, please visit this Link or call 01628 857311 or contact the Medical Practice. * Tick here to confirm that you have read the above:
PASSIVE SMOKING
Are you exposed to smoke at work?	Yes   No
Are you exposed to smoke at home?	Yes   No
* How often do you have a drink that contains ALCOHOL? Never (0) Monthly or less (1) 2-4 times / month (2) 2-3 times / week (3) 4+ times / week (4) * How many alcohol units per week do you drink?     NHS Alcohol Unit Calculator
* How many standard alcoholic drinks do you have on a typical day when you are drinking? 1-2 (0) 3-4 (1) 5-6 (2) 7-9 (3) 10+ (4)
* How often do you have 6 or more standard drinks on one occasion? Never (0) Less than monthly (1) Monthly (2) Weekly (3) Daily or almost daily (4)
If your total alcohol score above is high it may indicate hazardous or harmful drinking. Please then complete the more detailed questions below (score in brackets):   * How often during the last year have you found that you were not able to stop drinking once you had started? Never (0) Less than monthly (1) Monthly (2) Weekly (3) Daily or almost daily (4)   * How often during the last year have you failed to do what was normally expected from you because of your drinking? Never (0) Less than monthly (1) Monthly (2) Weekly (3) Daily or almost daily (4)   * How often during the last year have you needed an alcoholic drink in the morning to get yourself going after a heavy drinking session? Never (0) Less than monthly (1) Monthly (2) Weekly (3) Daily or almost daily (4)   * How often during the last year have you had a feeling of guilt or remorse after drinking? Never (0) Less than monthly (1) Monthly (2) Weekly (3) Daily or almost daily (4)   * How often during the last year have you been unable to remember what happened the night before because you had been drinking? Never (0) Less than monthly (1) Monthly (2) Weekly (3) Daily or almost daily (4)   * Have you or somebody else been injured as a result of your drinking? No (0) Yes, but not in the last year (2) Yes, in the last year (4)   * Has a relative or friend, doctor or other health worker been concerned about your drinking or suggested that you cut down? No (0) Yes, but not in the last year (2) Yes, in the last year (4)       Your alcohol score is: 0 0 – 7: Lower risk, 8 – 15: Increasing risk, 16 – 19: Higher risk, 20+: Possible dependence   If your score is 8 or more, your answers suggest you may be at increased risk of future harm to your health from drinking. Further information about this can be found at www.drinkaware.co.uk/alcohol-facts/alcoholic-drinks-units/how-much-is-too-much   Would you like the surgery to contact you to offer advice? Yes No Would you like us to contact you regarding a referral for further care? Yes No
Females only Have you ever been sexually active?Yes   No Do you require contraception?Yes   No   If you require the contraceptive pill, you will need to see a doctor or specialist sexual health nurse at the medical centre in the first instance to get this set up and issued.  Thereafter you will need to see a nurse for each contraceptive pill repeat.  (Those on Dianette will need to see a doctor) When was your last cervical smear/PAP? Not applicable   Date: Have you ever had an abnormal smear/PAP? Not applicable   No   Yes, date: Number of pregnancies:
Next of Kin Emergency Contact   Who is your next of kin? Who should we contact in an emergency (if different from your Next of Kin)? Full Name: Contact Number(s): Your Relationship:
Confidentiality
The practice treats the information you provide as confidential.
The following systems use your data and you will need to either opt in or opt out of the data extractions.
Summary Care Record (SCR) The NHS in England is using a national electronic record called the Summary Care Record (SCR) to support patient care. The Summary Care Record is a copy of key information from your GP record. It provides authorised healthcare staff with faster, secure access to essential information about you when you need unplanned care or when your GP practice is closed. Summary Care Records improve the safety and quality of your care. * Please express your agreement to this:   Opt in   Opt out
Local sharing via My Care Record Your patient record is held securely and confidentially on the electronic system at your GP practice. If you require attention from a health and social care professional such as an Emergency Department, Minor Injury Unit, social worker, or Out Of Hours location, those treating you would be better able to give you appropriate care if some of the information from the GP practice was available to them. This information can now be shared electronically via My Care Record. * Please express your agreement to this:   Opt in   Opt out
Organ Donation If you are interested in becoming an organ donor, please click this link to go to the organ donor registration page.
Blood Donation If you are interested in becoming an blood donor, please click this link to go to the blood donor website.
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