Please help us trace your previous medical records by providing the following information
Next of kin
Permission to use your details
Gender and sexual orientation
Further support for alcohol dependence is available from the surgery or from our local alcohol service Change Grow Live (Tel: 01274 296023)
Have you suffered from any of the following?
Would you like to nominate a local pharmacy where we can send your prescriptions?
Disabilities and other needs
It is important for us to identify and log a patient’s requirements in their medical notes if they have a recorded disability.
Ethnic group information
This practice, in line with other healthcare providers, collects information about the ethnic group that patients feel they belong to. You do not have to complete this form but if you do you will be helping us to help you. It will help us plan to deliver better services to our patients and ensure that everyone has equal access to the health care we provide.
All the information that we receive will be used and treated with the strictest confidence in the same way as other information that we hold. When used in the planning of services all names and other identifying details will be removed.
Providing the following information is optional.