New Patient Registration Form - Adult - Rowlands Road Surgery

Please complete all sections in full.

Last Updated: 02/05/2023

Contact Details

Other Details

Communication Needs

Carer Details

Medical History

Family History


Current Medication

Your Lifestyle

Please answer the following questions which are validated as screening tools for alcohol use.  Add up your score to each question.

A score of less than 5 indicates lower risk drinking. Scores of 5 or more requires the following 7 questions to be completed. Add up your score to each question.

Your Lifestyle - continued

Students Only

Students are at risk of certain infections including mumps, meningitis and sexually transmitted infections, as well as mental health issues including stress, anxiety and depression. Please see

Further Details

Organ Donation

You will automatically be considered that you agree to become an organ donor when you die unless you are under 18, have opted out or are in an excluded group.  For further information, please see:


Sharing your Health Record

What is your health record?

Your health record contains all the clinical information about the care you receive.  When you need medical assistance it is essential that clinicians can securely access your health record. This allows them to have the necessary information about your medical background to help them identify the best way to help you. This information may include your medical history, medications and allergies.

Why is sharing important?

Health records about you can be held in various places, including your GP practice and any hospital where you have had treatment. Sharing your health record will ensure you receive the best possible care and treatment wherever you are and whenever you need it. Choosing not to share your health record could have an impact on the future care and treatment you receive. Below are some examples of how sharing your health record can benefit you:

·         Sharing your contact details - This will ensure you receive any medical appointments without delay

·         Sharing your medical history - This will ensure emergency services accurately assess you if needed

·         Sharing your medication list - This will ensure that you receive the most appropriate medication

·         Sharing your allergies - This will prevent you being given something to which you are allergic

·         Sharing your test results   This will prevent further unnecessary tests being required


Is my health record secure?

Yes. There are safeguards in place to make sure only organisations you have authorised to view your records can do so. You can also request information regarding who has accessed your information from both within and outside of your surgery.

Can I decide who I share my health record with?

Yes. You decide who has access to your health record. For your health record to be shared between organisations that provide care to you, your consent must be gained.

Can I change my mind?

Yes. You can change your mind at any time about sharing your health record, please just let us know.

Can someone else consent on my behalf?

If you do not have capacity to consent and have a Lasting Power of Attorney, they may consent on your behalf. If you do not have a Lasting Power of Attorney, then a decision in best interests can be made by those caring for you.

What about parental responsibility?

If you have parental responsibility and your child is not able to make an informed decision for themselves, then you can make a decision about information sharing on behalf of your child. If your child is competent then this must be their decision.

What is your Summary Care Record?

Your Summary Care Record contains basic information including your contact details, NHS number, medications and allergies. This can be viewed by GP practices, Hospitals and the Emergency Services. If you do not want a Summary Care Record, please ask your GP practice for the appropriate opt out form. With your consent, additional information can be added to create an Enhanced Summary Care Record. This could include your care plans which will help ensure that you receive the appropriate care in the future.

How is my personal information protected?

Rowlands Road Surgery will always protect your personal information. For further information about this, please see our Privacy Notice on our website or please speak to a member of our team

For further information about your health records, please see:

For further information about how the NHS uses your data for research & planning and to opt-out, please see:

Online Access to your Health Record

I wish to have online access to:

I wish to access my medical record and understand and agree with each statement: Please tick all that apply

Please bring Photo Proof of ID e.g. Passport, Photo Driving License or Photo ID card and Proof of Address e.g. Bank statement, Utility Bill or Council Tax from within the last 3 months in order for the sign up process to be completed


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