New Patient Questionnaire

The doctors at the Practice do not carry out routine home visits.  Patients can receive a much more comprehensive and thorough assessment at the surgery, this includes children with temperatures.  Home visits ARE carried out for seriously ill patients such as those with a terminal illness and the disabled elderly.

We do not accept onto our practice list patients who are already registered with a doctor locally.  We also prefer that whole families are registered under the care of one medical practice; all members of the family need to be either registered here or elsewhere.

The doctors reserve the right to prescribe all medicines according to the best medical evidence currently available; for example we do not prescribe antibiotics and cough medicines for flu, common colds, most sore throats and coughs because there is no cure for these.

We will regularly review all repeat medications and sick notes rather than simply issuing them routinely, even if this has been the policy of a previous practice.

Drug addiction - WE DO NOT prescribe addictive medications such as Methadone.

We request that a registration medical is performed by a Health Care Assistant at the practice before registration, this is so we can gain pertinent medical information until we receive your complete medical records from your previous Health Authority.  You will be asked at this appointment to complete a GMS1 form in addition to this form.

Ideally you should print the completed forms, hand into the receptionists and book your registration medical appointment.

1Your Details

2Medical History - if you suffer from one of the following illnesses please enter the date of diagnosis

3Family History

4Current State of Health

5Women Only

6Medicines

7Allergies

8Immunisations

9Lifestyle

10Details of Alcohol Consumption

11Reason for changing Doctors

12Previous Doctor's details

13Please help us trace your medical records

14If you are from abroad

15If you are returning from the Armed Forces

16If registering a child under 5

17Opt Out Of Care Data

I am writing to decline my consent for my identifiable patient information to be transferred from your Practice for any purpose other than my medical care. Please code my records accordingly.

I do not wish my clinical data to be extracted electronically from this GP Practice. Please add the code 9Nu0 'Dissent from secondary use of GP patient identifiable data' to my medical records.

I am aware of the implications of this request and understand that it will not affect the care I receive. I will notify you should I change my mind.

18Text Message Reminder Service


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 known only to the GP practice and is accessed over a secure connection by nominated Practice staff. Our practice has 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.


© Dordon and Polesworth Group Practice 2018
Dordon Surgery - 162 Long Street, Dordon, Tamworth, Staffordshire, B78 1QA
Polesworth Surgery - High Street, Polesworth , Tamworth, Staffordshire, B78 1DU
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