New Patient Registration

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All questions marked with a * are mandatory

Patient's Details
Title: *
Including middle name(s)
Sex at birth: *

Please enter your full address.

If completing this on behalf of an under 16 year old, this must be the contact number for the Parent or Guardian completing this form
If completing this on behalf of an under 16 year old, this must be the email for the Parent or Guardian completing this form
Would you like to nominate a pharmacy for electronic prescribing?:
Nominate a pharmacy means we can send any prescriptions directly to the pharmacy without you needing to come to the surgery
include the full address and post code of your chosen pharmacy
E.g. single / married / divorced / widowed / other
Please list all other registered or registering members of your household, including dates of birth
Are you happy for us to contact you by email?: *
Are you happy for us to contact you by text message? : *
Have you been registered with this Practice before?: *
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NHS

Your NHS Number

Help us to help you

You do not need to know your NHS number to use NHS services. However, providing this reduces the time it takes to process your registration. It helps us get you registered quicker.

  How to find your NHS Number

Help us to help you.

 

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Ethnicity
Do you speak English?:
Do you read English?:
Will you require an interpreter when you see a clinician?:
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Next of Kin
Do you give us permission to discuss your medical records with them?: *
Are they your Emergency Contact?: *
Do you give us permission to discuss your medical records with them?:
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Previous Details
Are you registering for the first time in the UK? : *
Have you recently moved to the UK: *
Please include postcode
Are you returning from abroad?: *
If you are from abroad
Please use this date format: DD/MM/YYYY
Refugee: *
Asylum Seeker: *
Are you returning from abroad? : *
If you are returning from abroad

This assumes that you have previously been registered with the NHS in the UK

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Were you ever registered with an Armed Forces GP?
Were you ever registered with an Armed Forces GP?: *
Please indicate if you have served in the UK Armed Forces and/or been registered with a Ministry of Defence GP in the UK or overseas.

These questions are optional and your answers will not affect your entitlement to register or receive services from the NHS but may improve access to some NHS priority and service charities services

Please indicate if you have served in the UK Armed Forces and/or been registered with a Ministry of Defence GP in the UK or overseas:
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Supplementary Questions - If you are not a resident in the UK, but visiting or moving to the UK
New Patient Registration

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 at reception. Alternatively for more information go to the NHS Website

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 purposes 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 statements:: *
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European Economic Area (EEA) Country
Do you live in another EEA country, or have moved to the UK to study or retire, or live in the UK but work in another EEA member state?:
Do you have a non-UK European Health Insurance Card (EHIC) or a Provisional Replacement Certificate (PRC) ?:

Please Note

If you are visiting from another EEA country and do not hold a current EHIC (or Provisional Replacement Certificate (PRC))/S1, you may be billed for the cost of any treatment received outside of the GP practice, including at a hospital.

Please enter the details from your EHIC or PRC below.

S1 Form

Please upload a copy of your S1 form

  • You can upload a document, photo or scan
Only following file extensions are allowed: jpg, jpeg, png, webp, pdf, doc, docx, pptx

How will your 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.
  • This form collects personal and medical information about you and we use this information to allow the practice team to contact you.
  • 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.
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Carers

A carer is anyone, including children and adults who looks after a family member, partner, or friend who needs help because of their illness, frailty, disability, a mental health problem or an addiction and cannot cope without their support.

  • This is different from normal parenting duties for a child
Do you have a carer?: *
UK number only
If a company of organisation, please indicate which above.
If applicable
Do you give us permission to discuss your medical record with your carer?: *
Are you a carer for someone?: *
Please provide full name, date of birth, address, telephone number, GP details and relationship for the person you care for.
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Allergies
Do you have any allergies?: *
Please include any medication you are allergic to, if applicable
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Lifestyle

Your Height

What unit of measurement are you using?: *
Conversion from Feet & Inches to Centimetres

Your Weight

What unit of measurement are you using?: *
Conversion from Stones & Pounds to Kilograms
Your Smoking Status
Please choose from one of the following options: *
Stop Smoking

Steps to quit smoking

Stopping smoking lets you breathe more easily. People breathe more easily and cough less when they give up smoking because their lung capacity improves by up to 10% within 9 months.

  NHS Stop Smoking Services

  Take steps now to stop smoking

  10 self-help tips to stop smoking

Are you interested in further advice and support on how to quit?: *
Are you on a special diet?: *
How much exercise do you do?: *
Adult Females
Was it done at:
Have you had a hysterectomy?:
Do you still have your ovaries?:
Do you use contraception:
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Your Personal Alcohol Consumption

What does 1 unit of alcohol look like?

Each of the examples depicts 1 unit of alcohol based on the Alcohol by Volume (ABV) against the Volume (ml) displayed.

Click here for NHS guidance about calculating alcohol units

  • Cider

    Cider 218ml

    Standard 4.5% ABV

  • Wine

    Wine 76ml

    Standard 13% ABV

  • Whisky

    Whisky 25ml

    Standard 40% ABV

  • Beer

    Beer 250ml

    Standard 4% ABV

  • Alcopop

    Alcopop 250ml

    Standard 4% ABV

How often do you have a drink containing alcohol?: *
 
How many units of alcohol do you drink on a typical day when you are drinking?: *
How often have you had 6 or more units if female, or 8 or more if male, on a single occasion in the last year?: *
Your Personal Alcohol Consumption - Part 2
How often during the last year have you found that you were not able to stop drinking once you had started?: *
How often during the last year have you failed to do what was normally expected from you because of your drinking?: *
How often during the last year have you needed an alcoholic drink in the morning to get yourself going after a heavy drinking session?: *
How often during the last year have you had a feeling of guilt or remorse after drinking?: *
How often during the last year have you been unable to remember what happened the night before because you had been drinking?: *
Have you or somebody else been injured as a result of your drinking?: *
Has a relative or friend, doctor or health worker been concerned about your drinking or suggested that you cut down?: *
 
Baby Checks

6 to 8-week checks

Burdwood Surgery offers postnatal checks 6 to 8 weeks after your baby's birth to make sure you feel well and are recovering properly.

Your baby’s health will also be checked at this time and will discuss your baby’s vaccinations with you. The appointment is usually 20 minutes in length and will be with your own GP. We will contact you to book this appointment. If you have not heard from us, please contact reception to book an appointment. If your baby is older than 8 weeks, we will not be able to offer you this service.

  What to expect at your postnatal check

  What to expect at your baby’s 6 to 8-week

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Audit Score Result 0 - 7 (Lower Risk)

Lower Risk 

, you have a score of 

Your answers suggest you are at a lower risk of being dependent on alcohol.

  • If you are drinking less than 14 units of alcohol per week, then your drinking is within the UK Chief Medical Officers' low risk drinking guidelines.

Caution advised

If you are drinking regularly at or above the low risk guidelines of 14 units a week, or, you are drinking six or more units if you are female or eight or more units  if you are male in one single session (binge drinking), please consider the increased serious risks to your health being caused by your current drinking pattern.

Audit Score Result 8 - 15 (Increasing Risk)

Increasing Risk

, you have a score of 

Your answers suggest you are at an increasing risk of being dependent on alcohol.

Caution

  • Your drinking is dangerous to your health, increasing your risk of serious health problems including seven types of cancer, liver and heart disease, and high blood pressure.
  • Unless you cut down you are at risk of damaging your health.
Audit Score Result 16 - 19 (Higher Risk)

Higher Risk

, you have a score of 

Your answers suggest you are at Higher Risk of being dependent on alcohol.

Your drinking is dangerous to your health.

  • You are drinking far more than the UK Chief Medical Officers' low risk drinking guidelines of 14 units a week.
  • Regularly drinking this much causes a range of serious health harms including seven types of cancer, liver disease and high blood pressure.
Audit Score Result 20+ (Possible Dependence)

Possible Depandance

, you have a score of 

Your answers suggest you are at High Risk of being dependent on alcohol.

  • Your drinking is dangerous to your health.
  • You are drinking far more than the UK Chief Medical Officers' low risk drinking guidelines of 14 units a week.
  • Regularly drinking this much causes a range of serious health harms including seven types of cancer, liver disease and high blood pressure.

Alcohol Support

If you have become dependant on alcohol, you will have found it difficult to fully control your drinking in some way. So you'll probably need some help either to cut down and control your drinking or stop completely, and also some plans to maintain the improvement after that.

  Find Alcohol Support Services in your area

  Tips on cutting down

Baby Immunisations

Baby Immunisations

Burdwood Surgery offers baby and childhood immunisations.

Baby immunisations should be administered at 8 weeks, 12 weeks and 16 weeks. 

  • After your 6-to-8-week check with a GP, you will be directed to reception to book your baby’s 8-week immunisations with one of our Practice Nurses.
  • After your baby’s 8-week immunisations, our Practice Nurses will book you an appointment to have the 12-week and 16-week immunisations. 

It's important that vaccines are given on time for the best protection, but if you or your child missed a vaccine, contact us to catch up.

  Vaccinations

  Vaccinations and when to have them

  Vaccination appointment tips for parents
 

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Immunisation History
Have you had a rubella immunisation?:
Please include dates.
Routine Immunisations Schedule
Age Due 8 Weeks Old

Diseases protected against: Diphtheria, tetanus, pertussis (whooping cough), polio, Hib and hepatitis B

Diseases protected against: Meningococcal group B

Diseases protected against: Rotavirus gastroenteritis

Age Due 12 Weeks Old

Diseases protected against: Diphtheria, tetanus, pertussis (whooping cough), polio, Hib and hepatitis B

Diseases protected against: Pneumococcal conjugate

Diseases protected against: Rotavirus gastroenteritis

Age Due 16 Weeks Old

Diseases protected against: Diphtheria, tetanus, pertussis (whooping cough), polio, Hib and hepatitis B

Diseases protected against: Meningococcal group B

Diseases protected against: Hib and Men C

Age Due 1 Year Old (on or after 1st birthday)

Diseases protected against: Pneumococcal

Diseases protected against: Measles, mumps and rubella

Diseases protected against: Meningococcal group B

Age Due Eligible paediatric age groups

Diseases protected against: Influenza

Age Due 3 years and 4 months old (or soon after)

Diseases protected against: Diphtheria, tetanus, pertussis and polio

Diseases protected against: Measles, mumps and rubella

Age Due 12 to 13 Years Old (all sexes)

Diseases protected against: Cancers caused by HPV types 16 & 18 and genital warts caused by types 6 & 11

Second dose is 6 - 24 months after the first
Age Due 14 Years Old (School Year 9)

Diseases protected against: Tetanus, diphtheria & polio

Diseases protected against: Meningococcal groups A, C, W and Y

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Medical History
Please include dates.
Please include dates.
Please include dates of any family history illnesses.
Do you take regular medication?: *
Would you like to upload a copy of a repeat prescription list:

Please upload a copy of your Repeat Prescription

  • You can upload a document, photo or scan
Only following file extensions are allowed: jpg, jpeg, png, webp, pdf, doc, docx, pptx
Please make sure you have a month’s supply from your previous practice for prescribed medication.

It is our protocol for all new patients on regular medication(s) to speak to a GP for a medication review before any prescription can be issued.

  • This will usually be a telephone call with a GP. Medication can then be placed on a repeat therapy list and this will enable you to order future prescriptions.
  • To ensure there is no delay with you obtaining your medications, please book a medication review with a clinician via our Reception team
How do you describe your sight?:
How do you describe your hearing?:
Do you have any information or communication needs?: *
i.e. hearing impairment, visual impairment, learning disability etc
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Summary Care Record

Summary Care Record (SCR)

The Summary Care Record (SCR) system is designed to help both your GP and any emergency staff you contact when the surgery is closed to treat your health needs more efficiently.

  • Your information will be shared between your GP practice, our local hospital and Out Of Hours service.
  • This will enable your GP surgery to access results and any visits you have at the hospital quickly and efficiently, but it also means that if you have an emergency and contact the Out Of Hours service or visit A&E they will have access to your current medications as well as allergies and are better able to treat you.
SCR Options:

If you do not complete this section, a Summary Care Record will be created for you based on implied consent

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NHS Logo

Patient  Identification

We are a Safe Surgery for everyone in our practice area.

Everyone in the UK has the right to free care from a General Practitioner (GP). If you don’t have proof of ID or address, you can still register with us.

We might ask for ID or proof of address. But if you don’t have any and you live in our practice area, you can still register with us.

Acceptable forms of Photo ID

  • Photo Driving License
  • Passport

ID documents are not stored and will be securely destroyed in line with our data retention schedule.

Acceptable forms of Proof of Residence

  • Tenancy agreement
  • Mortgage statement
  • Bank statement
  • Utility bill (date within the past 3 months) 

Please upload a copy of your ID and Proof of Address

  • You can upload a document, photo or scan
Only following file extensions are allowed: jpg, jpeg, png, webp, pdf, doc, docx, pptx
Only following file extensions are allowed: jpg, jpeg, png, webp, pdf, doc, docx, pptx
Only following file extensions are allowed: jpg, jpeg, png, webp, pdf, doc, docx, pptx
Parent Group Activitities

West Berkshire Family Hub 

Family Hubs offer a range of services to support families, parents and carers of children aged 0 to 19 years old

  • (0 to 24 for children with special educational needs and disabilities)

Families with children under 5 can access services including 1-to-1 support, a variety of groups and family learning courses.

There are a number of different events and sessions at each of the Family Hubs.

  More information about Family Hubs

  Central Family Hub (nearest to Burdwood Surgery)

  Book an Event or Session

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The NHS App

Burdwood Surgery would like to invite you to use The NHS App

Owned and run by the NHS, the NHS App is a simple and secure way to access a range of NHS services on your smartphone or tablet.

MORE INFORMATION

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Anima
anima

anima

Accessing our services for non-routine requests

If your query cannot wait until our next routine appointment, you will need to submit your query via Anima.

Each form is suited to your medical or administrative query. This will allow us to review your symptoms and direct you to the best person as quickly as possible.

More information about anima

We recommend that you sign up as soon as possible.

  • You can use your existing NHS App Login to create an account.
  • You can also create proxy access for a relative or dependent so you can submit requests on their behalf.
  • If you need to fill in the Anima form for an appointment today, please phone reception to inform us of your registration.
    This is because we will need to add you to our clinical system before you can complete an Anima request.

SIGN UP NOW

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Organ Donation

NHS Organ Donor registration

The law around organ donation in England changed to an opt-out system, to enable more people to save more lives.

This means that unless you choose to opt out, or are in an excluded group, you will be considered to have agreed to be an organ donor when you die.

The best way to make your decision known is to record it on the NHS Organ Donor Register and tell your loved ones.

  Find our more about Organ Donation

Yes I do donate

Across the rest of the UK

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Blood Donor

NHS Blood Donor registration

Giving blood saves lives.The blood you give is a lifeline in an emergency and for people who need long-term treatments.

This means that unless you choose to opt out, or are in an excluded group, you will be considered to have agreed to be an organ donor when you die.

The best way to give blood is to apply using the NHS Blood Donor Register

  Find our more about Blood Donation

Yes I do donate

We need

  • Nearly 400 new donors a day to meet demand
  • Around 135,000 new donors a year to replace those who can no longer donate
  • 40,000 more black donors to meet growing demand for better-matched blood
  • 30,000 new donors with priority blood types such as O negative every year
  • More young people to start giving blood so we can make sure we have enough blood in the future
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Alcohol Consumption Self-Assessment

Zero Tolerance

  • Nationwide, GP surgeries are experiencing increased demand for services, and we know it can be frustrating when appointments are in short supply.
  • We would like to take this opportunity to remind you that our staff are doing their best to help you, will often go the extra mile, and do not deserve to be spoken to in a rude or offensive manner.

We take abuse of our staff very seriously and will not tolerate it.

Please treat our team with the kindness and understanding that you expect in return.

  • If you wish to discuss any aspect of registration, our Patient Services Manager will be pleased to answer your queries.
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Patient Participation Group

Patients' Participation Group (PPG)

The Burdwood Surgery Patients Participation Group (PPG) is made up of a number of patients and staff who have volunteered to be members of the PPG.

The PPG acts as a liaison group between you, the patient, and the Doctors and staff of the Practice.

Every three months (usually on a Saturday morning) we hold a meeting that lasts about an hour and a half, in a friendly and informal atmosphere here at the surgery. Tea, coffee and biscuits are provided!

Everyone is welcome and together we can make things happen!

In the past we have discussed changes that are going to affect the NHS, your local Health Service and local hospital services. We also discuss proposed developments within the Surgery, services that we offer, staff changes, opening hours and extended hours, and any issues that affect our patients.

We are always keen to welcome new members to our meetings and to capture any feedback you have. We would like to hear what you have to say.

If you feel you would rather represent the group without having to attend a meeting, we also have a ‘virtual’ Patient Representation Group (PRG) to run alongside the PPG. Members receive all current PPG information and minutes electronically and from time to time are sent a short mini survey with questions such as what you think about our opening times or the quality of the care or service you received.

We will contact you via email, our surveys succinct so it shouldn’t take too much of your time.

Would you be willing to join our PPG (Patient Participation Group)?: *
Would you be interested in joining the ‘virtual’ PRG (Patient Representation Group), where you could contribute electronically?: *
Would you like to receive the minutes of our meetings?: *
Are there any issues you would like to see on the agenda?: *
Do you have a special interest in a particular medical condition?: *

Confirm your details

  • Please return to 1st page to make any corrections

Address: %%form-element-3940%%
Postcode: 

Email: 
Mobile: 

Prefered Method of contact: *
Back Pain

First Contact Physiotherapy

At Burdwood Surgery, we offer an advice and assessment service for those who have a musculoskeletal (MSK) problem. 

They can help with women’s health MSK problems such as pelvic gridle pain, diastasis recti and pregnancy related back pain.

They can help patients who are currently pregnant and those who have recently had a baby.

MORE INFORMATION ABOUT THE SERVICE

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What happens to my information?

  • Personal and medical information about patients registered at this practice are primarily kept electronically, although some is kept in paper form. Some information will be sent to hospital consultants and other health professionals to whom you are referred by your GP in order to provide continued healthcare and obtain treatment for you.
  • We sometimes use accredited suppliers for our communication with you, for example when we send recall letters for review clinics or medication reviews. All suppliers we use are checked carefully to ensure they comply with strict confidentiality protocols.
  • To ensure the security of all patient information, all staff that has access to your records is covered by confidentiality clauses in their contracts and the Data Protection Act and the Freedom of Information Act. Our guiding principle is that we hold your records in strict confidence.
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Privacy Consent

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