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Call 111 - When it is less urgent than 999
Engagement on closure of Aksyr Medical Practice

New Patient Health Questionnaire

If you are registering a new patient under the age of 16, you will need to provide reception with details of their immunisations.  The registration will not be processed without this information.

New Patient Health Questionnaire

Do you have any of the following conditions? If yes, please provide details includingyear of diagnosis

Lifestyle

1 unit is half pint of regular beer, lager or cider, one very small glass of wine, one single measure of spirits, one small glass of sherry, one single measure of apertifs

Medication History

Please list all the medicines you use including those you buy from the chemist

Women Only
Questions if you are registering a patient under the age of 16 years

Privacy Protection

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.

Learn more about our Privacy Policy and Terms of Use. Should you have any concerns about sending your personal details using the web, please use one of the alternative methods offered by our organisation.


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