New Patient Registration - Additional Questions

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Have you completed the NHS Registration forms?
You are unable to continue completing this form:

We will be unable to complete this part of the registration process if you have not completed the NHS Registration Forms first

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All questions marked with a * are mandatory

Patient's Details
Title: *
Including middle name(s)
Sex at 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?: *
What is your marital status:
E.g. single / married / divorced / widowed / other
Please list all other registered or registering members of your household, including dates of birth
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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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Language
  
Do you speak English?:
Do you read English?:
 
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Were you ever registered with an Armed Forces GP
Were you ever registered with an Armed Forces GP?: *

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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Adult Females
Was it done at:
Have you had a hysterectomy?:
 
Do you still have your ovaries?:
Do you use contraception:
Immunisation History
Have you had a rubella immunisation?:
Please include dates.
Under 16's Immunisation 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

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 of any family history illnesses.
Please include dates.
Lifestyle
Are you on a special diet?: *
How much exercise do you do?: *
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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

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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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!

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. Everyone is welcome and together we can make things happen!

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?: *
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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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Privacy Consent

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