Adult Registration

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    Step 1

    NOTICE: Before you complete the form please use the postcode checker below to see if you are within our area. If you are within our area please choose a surgery and press next.

    Please choose the location where you wish to be registered:


    Patient Details

    * Star is to show which boxes must be completed.

    Is your gender the same as assigned at birth?


    *Date of Birth (Day / Month / Year )

    / /


    Have you previously been registered with a Swan Surgery Medical Group Surgery?


    If yes which surgery?

    Swan Surgery, PetersfieldLiphook Village SurgeryLiphook Station Road SurgeryLiss, Hillbrow Road Surgery

    Medical Records

    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

    Where did you last receive Treatment?

    What was the outcome of this visit? ie prescription

    If you are from abroad

    Your first UK address when you registered with a GP

    If previously a resident in UK you are REQUIRED to tell us the date you first came to the UK. Also, please tells us the date of leaving.

    If you are returning from the Armed Forces

    Address before enlisting

    Are you a dependent of a family member currently serving in the armed forces?


    If yes, are you a spouse or a child?


    Care Services

    Please tell us about yourself

    Are you a carer?


    I the carer consent to my details being stored on the records of the person who is named as the patient on this form and subsequently the carers register.

    Do you have a carer?


    If yes, please tell us the name & address of your carer

    Are you happy for us to contact your carer about you?


    Are you or your children currently under the care of any external agencies/services eg Social Services. If so, please give details below:

    In general, do you have any health problems that require you to limit your activities?


    In general, do you have any health problems that require you to stay at home?


    Do you regularly use a stick, walker or wheelchair to get about? (Please tick appropriate)

    In case of need, can you count on someone close to you?


    Do you need someone to help you on a regular basis?


    Medical Information

    Personal Medical History

    Have you ever suffered from any important medical illness, operation or admission to hospital? If so please enter details below:

    Is the condition ongoing?YesNo

    Is the condition ongoing?YesNo

    Is the condition ongoing?YesNo

    Do you have any disabilities?


    If yes what are your disabilities?

    Do you need any reasonable adjustments?


    If yes what are the adjustments?

    Family History

    Have any close relatives (father, mother, sister, brother only) ever suffered from any of the following: (please indicate who in the boxes)

    Heart Attack



    High blood pressure





    State the nearest year in each box, if known.


    Please list any allergies you have to any drugs/medication.


    Please enter your height & weight.

    Lifestyle Smoking

    Do you smoke


    If yes, do you smoke:

    Are you an ex-smoker?


    When did you give up?

    How many cigarettes/cigars do you smoke daily:

    If you smoke a pipe how many ounces a week?

    Would you like help to quit smoking?


    If you are a smoker and would like help and advice on how to give up, please contact Quit4Life: 0845 602 4663 or go to


    Do you drink alcohol:


    If yes, please answer the following question.

    How many alcoholic units do you drink per week on average?(Units guide:Single spirit = 1 unit Small wine (125ml) = 1.5 units Pint beer = 2 units)

    Lifestyle exercise

    Do you exercise?


    If yes, What exercise do you do? How often do you exercise?

    Female patients only

    Are you currently, or think you may be pregnant?


    If you have any children how many?

    Which method of contraception (if any) are you using at present?

    If you have had a Coil fitted, what date:

    Have you had a cervical smear test?


    If yes, when was it and what was the result, if known?

    Other Information


    Do you require an interpreter?


    Next of kin

    For Patients aged 65 and over

    Do you hold a living will/


    (Documentation regarding your personal wishes in respect of medical intervention at the time of serious illness, i.e. resuscitation etc)

    Pharmacy Nomination

    We can now send your prescriptions to the pharmacy electronically for you, reducing the amount
    of paper used and making collecting your prescription easier for you. Please fill in the details
    below so that we can add them to the system. We will clear any previously nominated pharmacy
    as part of our registration process so you will need to complete the section below, even if you
    already have a nominated pharmacy.

    Pharmacy Address

    Data sharing consent choices

    Care and Health Information Exchange (CHIE)

    The Care and Health Information Exchange (CHIE) is a secure system which shares health and social care information from GP surgeries, hospitals, community and mental health, social services and others. CHIE helps professionals across Hampshire, the Isle of Wight and surrounding areas provide safer and faster treatment for you and your family by:

    • Ensuring that you only have to tell your story once

    • Reducing delays to your treatment. For example, by reducing the need to repeat blood tests

    • Making sure the doctors, nurses and others involved in your care know about your medical history

    • Identifying diseases that you might be at increased risk of developing in the future. This can help you take action early to protect your health

    CHIE contains health and social care information from over 150 GP surgeries in and around Hampshire and the Isle of Wight, as well as local hospitals, community health, mental health and social care teams in order to help coordinate and improve your care. CHIE shows the medication you are currently taking, your allergies, test results and other important medical and care information. Health and care staff can see this information if they need to know about your previous history.

    For more information please visit:

    After reading the information above CAREFULLY please tick your choice below:

    Summary Care Record (SCR)

    The Summary Care Record (SCR) is a national scheme and is used to support your emergency care nationwide. It will contain important information about medicines you are taking, any bad reactions or allergies to medications, your significant medical history and information about any long-term conditions. Giving healthcare staff access to this information can prevent mistakes being made when caring for you in an emergency or when your GP practice is closed. Your Summary Care Record will also include your name, address, date of birth and your unique NHS Number to help identify you correctly.

    After reading the information above CAREFULLY please tick your choice below:

    In accordance with the Data Protection Act, we need your consent to carry out the following:

    (Please tick below if you consent)

    Send text reminders


    Many people find it useful to have important messages sent to them via text messages. Here at The Swan Medical Group we can use texts to keep you informed about your appointments and if there are any issues or news about the practice.

    Leave voicemail on mobile


    Leave voicemail on landline


    Leave voicemail on both


    To make life a little easier we can leave messages on your phone either at home or on your mobile. You should be aware that your messages may be picked up by another person at home or if you don’t keep us informed of a number change.

    DISCLAIMER – If you agree to the practice contacting you via your mobile phone or fixed landline number, we agree to adhere to the following;

    1.The mobile number or fixed landline number will only be used by the practice and will not be passed to any other parties

    2.If at any time you would like to opt out of either of the above services, please make a written request to the practice and you will be opted out of the service within 48 hours. You may also like to include your reason for opting out to help us review and improve the service in future

    3.Your mobile phone number will solely be used by the practice in relation to the healthcare services offered by the practice. You will not be contacted in relation to any other types of products or services


    I confirm that the information I have provided is true to the best of my knowledge.

    Postcode Checker

    Please click on the search icon top right of the map, and enter your postcode into the box provided to see if your postcode is in our catchment area. If you are within our area continue with the form.