Patient Registration for Brownlow Health Central

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 practice to do so.
Please do not use this form to update your address or other details.

IMPORTANT.  Please note that Brownlow Health has multiple practices, so you need to make sure that you are filling in the correct registration form for your chosen practice. This form is for registering with 'Brownlow Health Central' (which includes the Student Health Centre).  For details of the other practices, please click here. * I have read and understand this:
* Please select one of the following:		I live within the practice area (students and non-students) OR I am a University of Liverpool student living in L15, L17 or L18 (click here for practice area information) I live outside of the practice area, and would like to apply to be an ‘out of area’ patient
* Out of Area (OOA) suitability questionnaire The current regulations require GP practices to determine whether it is clinically appropriate or practical to accept an application from a patient for Out of Area registration without the requirement to provide home visits or urgent GP services at their place of residence. We have therefore designed this questionnaire to get to know more about your health to ensure you receive the best possible care. If we register you as an OOA patient and it later becomes apparent that it is not clinically appropriate or practical for you to be an OOA patient we will ask you to register elsewhere and we will remove you from our practice list. The information below is a true reflection of my current health:   Conditions and characteristics     1. I am over the age of 18 Yes No 2. I accept that if I develop any future medical conditions, I will require a reassessment by the Practice regarding my suitability to remain registered as an Out of Area patient. Yes No 3. I accept that if needed a member of staff from Brownlow Group Practice may contact me for more information regarding my health circumstances. Yes No 4. I am usually housebound Yes No 5. I have a long-term medical condition which has previously required, or likely to require, a home visit Yes No 6. I am currently engaged with local community services (eg Careline, Social Services, Health Visitors, District Nurses, Counselling or Mental Health Services, Drug & Alcohol Services, midwives) near my main home Yes No 7. I am currently under the care of a psychiatrist or local Mental Health Team Yes No 8. I am currently receiving end of life care Yes No 9. Whilst my home address is out of area I have ongoing links to the area where the practice is located with work, studies, or other links that make it preferable for me to be registered with Brownlow Yes No
* Title:		Mr   Mrs   Miss   Ms
* Family/Surname:
* First name(s):
Previous surname(s):
* 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):
		Contact your old surgery to get your NHS number. Failure to do so will slow down your registration.
* Gender:		Male  Female
* Town and country of birth:
University (if applicable):		Select university University of Liverpool Liverpool John Moores University Other university or college
Year due to finish university (if applicable):		Year 2023 2024 2025 2026 2027 2028 2029 2030 2031 2032 2033 2034
Please fill in this section if you live in University Accommodation
Address in Liverpool: (university accommodation) Room or Flat No:		Please select... Agnes Jones House Ablett House Apollo Court Arena House Arndale House Arrad House Arts School Loft Atlantic Point Village 2-33 Atlantic Point Village 24-49 Atlantic Point Village 50-65 Atlantic Point Village 66-80 Atlantic Point Village 85-97 Atlantic Point Village 98-199 Atlantic Point Village 120-127 Atlantic Point Village 128-135 Atlantic Point Village 136-151 Atlantic Point Village 152-167 Bedford Street South Borden Court The Bridewell Bridgewater St Byrom Point Cambridge Court 1-61 Cambridge Court 62-114 Camden St Capital Gate Cedar House Chancellor Court 1-29 Chancellor Court 30-77 Chancellor Court 78-105 Chatham Lodge City Point Crown Place Dean Patey Court Derby Buildings Dillstone Court Dover Court Europa Falkand House Gerald Manley Hopkins Hall Grand Central 2-75 Grand Central 76-150 Grand Central 151-225 Grand Central 226-288 Grand Central 289-369 Grand Central 370-448 Great Crosshall Street (Even Num) Great Crosshall Street (Odd Num) Great Newton House Greenbank Student Village Grenville St South Grove St Studios Hahnemann Studios Haigh Court 117 Hayward House 119 Hayward House Heritage Court Hope St Apartments Jamworks L1 Building Lady Mountford House Larch House Largo Court Lennon Studios Libertas Liberty Park Lime Court 4 Marybone 7 Marybone 14 Marybone McNair Hall Melville Grove Monument Buildings Morton House Moss Street Mostyn Hall Mount Pleasant My Student Village Myrtle Court Myrtle Parade Norfolk House North Western Halls Oliver House Parliament Place Parr Court Penny Lane Student Halls Penta House Philharmonic Court Plato House Prospect Point Queensland Place Rankin Hall Roscoe & Gladstone Hall Saint Cyprians Salisbury Hall St Andrews Gardens Stanley Street 19 - 23 Streatlam Tower The Arch The Artesian The Cableyard The Electra The Lightbox The Lodge The Octagon The Paramount The Quadrant The Railyard The Sidings Tinlings Trueman Hall Victoria Court Victoria Hall Vine Court Windsor Court Woodside St X1 Liverpool One X1 The Edge X1 The Studios
Please fill in this section if you do not live in University Accommodation, OR if your accommodation is not on the drop-down list above
Address in Liverpool: (not university accommodation)
* Town:
* Postcode:
* E-mail address:
* Confirm E-mail address:
* UK Mobile telephone number:
We find that SMS/text messaging and email are often the most efficient methods of contacting patients about routine matters e.g. to remind you of an appointment. We will never use text or email to send confidential medical information.
* May we contact you by email? Yes    No * May we contact you by SMS/text? Yes    No
Please help us trace your medical records by selecting if you are from UK or abroad (Part 1) and then filling in the next section (Part 2)
* Part 1. Select if you are from UK or abroad:		I'm from UK I'm from abroad
Part 2: Fill in if you come from the UK * Previous Address in UK: (i.e. last address before moving here) * 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 patient) * 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 Study Visa expiry date: 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 2018 2019 2020 2021 2022 2023 2024 2025 2026 2027 2028 2029 2030 2031 Have you lived or studied in the UK before? Yes    No Your first 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
Full name: EMERGENCY CONTACT   Phone no:    Relationship:
Height:  cm Weight:  kg
Think about all the moderate Physical Activities that you do in a typical week: Moderate activities refer to activities that take moderate physical effort and make you breathe somewhat harder than normal. This may include brisk walking, gardening, dancing, cycling, exercise and sport which last for at least 10 minutes. On average, how many days per week do you do moderate physical activities? Days per week On those days, how much time did you usually spend doing moderate physical activity per day? Minutes per day
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:     Religion:         1st language: Need interpreter: Yes   No     Occupation:
Are you a carer? Yes  No  Do you have a carer? Yes  No
Please tick if have, or have had, any of the following ILLNESSES: Asthma: COPD: Heart problems: High blood pressure: Diabetes: Stroke: Thyroid problems:  Mental health problems: If you suffer from DIABETES, please tell us the name of your CONSULTANT and HOSPITAL: Diabetes TYPE: Diabetes Diagnosis DATE: Type 1  Type 2 Please list any other existing or past SIGNIFICANT MEDICAL CONDITIONS including major operations and dates: Please list any CURRENT MEDICATION, including inhalers. Please specify dose: Please list any significant FAMILY HISTORY of illness: Please list any DRUG ALLERGIES or ALLERGIC REACTIONS:
Have you ever been a member of the ARMED FORCES including the T.A.? Yes  No
OVER 45: Have you had any broken bones since aged over 45? Yes  No
WOMEN OVER 25: Have you ever had a smear test? Yes  No  Please enter date:   All women over 25 should have a routine smear test and our reception team will invite you to make an appointment for this potentially lifesaving test. Please ask if you have any concerns.
Do you SMOKE? Yes   No   Used to smoke
Amount you used to smoke per day:      When did you stop? Amount you smoke per day:
How often do you have a drink that contains ALCOHOL? Never Monthly or less 2-4 times / month 2-3 times / week 4+ times / week 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 3-4 5-6 7-9 10+
How often do you have 6 or more standard drinks on one occasion? Never Less than monthly Monthly Weekly Daily or almost daily
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)   Scoring (add up score in brackets): 0 – 7 Lower risk, 8 – 15 Increasing risk, 16 – 19 Higher risk, 20+ Possible dependence
Do you have a Disability?   Yes   No Please describe your disability: Please provide your preferred means of communication: Text:  Email:  Sign Language:  Hearing Loop:  Other: * Please note not all information is currently readily available *
Organ Donation If you are interested in becoming an organ donor, please click this link to go to the organ donor registration page.
NHS Records
There are strict laws and regulations to ensure that your health records are kept confidential and can only be accessed by health professionals directly involved in your care.  There is some sharing of information as detailed below.  You can opt out of any of these at any time if you wish.
NHS Summary Care Record (SCR) - this is an electronic record which contains information about the medicines you take, allergies you suffer from and any bad reactions to medicines you have had.  Having this information stored in one place makes it easier for healthcare staff to treat you in an emergency, or when your GP practice is closed.
	I agree to opt in   I do not agree to opt in
ONLINE SERVICES
We offer online services so that you can have access to your medical record. If you would like online access to book/cancel appointments, order repeat prescriptions, amend your contact details, view your medical record and message the practice please tick this box : You will need to present at reception to verify your identity before access can be given.
How did you hear about us? Select... Internet/Social Media Advertisment Word of mouth Friends/Colleagues Other:
Please read our Privacy Notice.

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.