Registration with a Family Doctor Form

## Patient Registration Form **Date of Registration:** 01 November 2024 **Patient Details:** * **Full Name:** Sarah Elizabeth Jenkins * **Date of Birth:** 15/03/1990 * **Gender:** Female * **Address:** 14 Willow Creek Lane, Brighton, BN1 6FG * **Phone Number:** 07700 900123 * **Email Address:** sarah.jenkins@example.com * **NHS Number (if known):** 987 654 3210 **Emergency Contact Information:** * **Name:** David Jenkins * **Relationship:** Husband * **Phone Number:** 07700 900456 **Medical History:** * **Allergies:** Penicillin (rash, swelling) * **Current Medications:** Sertraline 50mg daily, Folic Acid 400mcg daily * **Past Medical History:** Mild Asthma (childhood), Seasonal Allergies * **Previous Surgeries:** Appendectomy (2005) * **Family Medical History (relevant conditions):** Mother – Type 2 Diabetes, Father – Hypertension **Lifestyle Factors:** * **Smoking Status:** Non-smoker * **Alcohol Consumption:** Occasional social drinker (2-3 units per week) * **Exercise Habits:** Moderate (walks 3-4 times a week) **Preferred Pharmacy:** Boots Pharmacy, 23 High Street, Brighton, BN1 1LE **GP Declaration:** I, Dr. Eleanor Vance, confirm that Sarah Elizabeth Jenkins has been registered with our practice as of 01 November 2024. **Signature of GP:** Dr. Eleanor Vance (via electronic signature) **Patient Consent:** I, Sarah Elizabeth Jenkins, confirm that the information provided above is accurate to the best of my knowledge and I consent to my medical information being held by [Practice Name] for the purpose of my healthcare. **Signature of Patient:** Sarah Elizabeth Jenkins (via electronic signature)