Reception: Register as a new patient
Welcome to Clarendon Lodge Medical Practice. Please complete the form below to register yourself with the practice. We offer all patients, registering with the Practice, a “new patient consultation”. We strongly recommend that you make an appointment because the information gained at this meeting and through the questionnaire, helps us to provide you with the best care and attention possible.
Please see the links below on a variety of topics related to this form
Please do not write any clinical queries on this form. Any clinical queries or request for appointments via this form will be discarded. To make an appointment either book online via the NHS app/Patient access or by calling reception 01926 331401. We will start to process your form by the next working day but it will take up to 5 working days to complete. Please DO NOT call before 5 working days as you will not receive a status update from reception or the administrative team. If you are NOT a registered patient then your form will be discarded. This service is only for patients registered at the surgery aged 16 and over; and for parents or legal guardians of children. Forms must be completed in the UK due to GDPR regulations.
Reception: Register as a new patient
We will need to trace your previous medical records so please provide us with the following information:
If you are from abroad (Leave this section blank if this does not apply)
If you are returning from the Armed Forces
If you are registering a child under 5
NHS Organ Donor Registration
For more information visit www.uktransplant.org.uk or call 03001232323
NHS Blood Donor registration
For all patients who are NOT ordinarily resident in the UK (Please leave this section blank if this does not apply to you)
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 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, exemptions 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 pract
Non-UK European Health Insurance Card (EHIC) or Provisional Replacement Certificate (PRC) (Please leave blank if not applicable)
S1 form (please leave blank if not applicable)
Please give your S1 form to practice staff.
How will your EHIC/PRC/S1 data 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 purposes 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.
Admission to hospital
Drugs & Medicines
If yes please state below
Please add your scores together from the previous 3 questions - A total of 5+ indicates increasing or higher risk drinking. If you score 5+ we recommend that you make an appointment with one of our nursing team.
Consent to communicating with you
To ensure that we comply with the new General Data Protection Regulations we need to ensure that you consent to the way we contact you and would appreciate it if you could complete the following questions.
We will use the mobile number supplied by you for this communication, so please consider if this is shared with others.
It is your responsibility to advise us of changes to your mobile phone number.
We will use the email address supplied by you for this communication, so please consider if this is shared with others.
It is your responsibility to advise us of changes to your email address.
Summary Care Record (SCR)
PLEASE ENSURE THAT YOU HAVE READ THE INFORMATION LINKED ABOVE WITH REGARDS TO YOUR SUMMARY CARE RECORD
If you decided to proceed, but at any time in the future you choose not to have a Summary Care Record, all you need do is write to your Surgery informing them of your decision to “Opt-out”. If you have already told your Surgery that you wish to “Opt-out” and you wish this to remain in place you need take no further action.
Accessible Information Standard
As part of the accessible information standard we wish to make sure that patients and service users, and their Carers and parents, can access and understand the information they are given by Clarendon Lodge Medical Practice
If you have any information or communication needs- which relate to a disability, impairment or sensory loss. We can provide for instance letters in large print or Braille, or if you require an interpreter/ translator for consultations with the Doctor or Nurse.
Electronic Prescription Service (EPS)
Application for online access to my medical record
If you have nominated a Pharmacy previously using this system and then recently joined our Practice – please ensure that your nominated Pharmacy is up to date – either with the Practice or your new Pharmacy of your choice.
For more information on the Electronic Prescription Service visit – www.connectingforhealth.nhs.uk/eps
If you wish to use the Electronic Prescription Service – please ask at your local Pharmacy or at Reception at Clarendon Lodge.
Please complete the Nomination form below to enable us to update your records if you wish to use this service.
Please ensure that you have read through the information linked at the top of the page with regards to online access.
1. I have read and understood the information leaflet provided by the practice
2. I will be responsible for the security of the information that I see or download
3. If I choose to share my information with anyone else, this is at my own risk
4. I will contact the practice as soon as possible if I suspect that my account has been accessed by someone without my agreement
5. If I see information in my record that is not about me or is inaccurate, I will contact the practice as soon as possible
State name & postcode
Information submitted through secure forms is used only for the purposes of processing your request. We may
be in touch with you in relation to the information submitted.
All Information submitted through secure forms is secured with a private key and is accessed over a secure
connection by nominated staff. We have a strict confidentiality policy.
This information is not shared with any third party organisations.
This information is retained for up to 28 days.
Should you have any concerns about sending your personal details using the web,
please use one of the alternative methods offered by our organisation.