Cottage Lane Surgery

47 Cottage Lane, Gamesley, Glossop, Derbyshire, SK13 6EQ

Telephone: 01457 861343

ddicb.cottagelanesurgery@nhs.net

Sorry, we're currently closed. Please call 01457 861343

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Online Registration

Family Doctor Service Registration

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Patient details

Title*

Date of Birth*

DD slash MM slash YYYY

Gender*

NHS Number

First Names*

Birth Town*

Surname*

Birth Country*

Previous Surname

Current Address and Postcode*

Telephone*

Mobile*

Email Address*

Please help us trace your previous medical records by providing the following information

Have you previously been registered with an NHS GP in UK?*

Yes

Name of Previous GP*

Address of Previous GP*

Your Previous Address

This is usually the address when you were last registered with a GP

Your first UK address*

Date you first came to UK

DD slash MM slash YYYY

Are you returning from the Armed Forces?*

Yes

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

Regular

Reservist

Family Member

Address and Postcode before enlisting*

Service or Personnel Number*

Enlistment date*

If you are registering a child under 5

Child Health Surveillance

I wish the child above to be registered with the named doctor for Child Health Surveillance

If you need a doctor to dispense medicines and appliances

Nearest Chemist

I live more than 1 mile in a straight line from the nearest chemist

Chemist Difficulty

I would have serious difficulty in getting them from a chemist

About You

Height*

Weight*

What is your first language?*

Do you need an interpreter?*

Yes

Ethnic Group*

White British

White Irish

White Other

Black Caribbean

Black African

Black Other

Indian

Pakistani

Chinese

Asian - Other

White + Black Caribbean

White + Black African

White + Asian

Other

Medical Information

Please list any illnesses/operations, accidents, disabilities and for women any pregnancy related issues you have had and the year they took place.*

Are you on any repeat Medication? (Please list if so)

Nominated Pharmacy*

Were you registered as Housebound at your previous practice?*

Yes

Have you ever suffered from:

Epilepsy

Blindness/Glaucoma

High Blood Pressure

Diabetes

Heart Attack

Stroke

Cancer

Asthma

Eczema

Hayfever

COPD

Hearing Loss

If yes to any of the above, when were they diagnosed?

Are you allergic to any medicines?*

Yes

Please state*

Have you ever refused treatment or screening of any kind?*

Yes

Please state*

Have you ever suffered from Anxiety, Depression, OCD, Bipolar Disorder?*

Yes

Please state, and when was it diagnosed?*

Any other mental health issues?*

Yes

Are you or have you in the past received any treatment or therapy regarding your mental health?*

Yes

Please state*

WOMEN ONLY - Have you ever had a cervical smear?*

Yes

Do you know the result and when?*

Do you have a carer?*

Yes

What is their name, address and contact number?*

Are you a carer?*

Yes

What is the name of whom you care for, their address and contact number?*

Do you have a learning disability?*

Yes

Military Veteran

Cottage Lane Surgery is a “veteran friendly” practice and deliver the best possible care and treatment for patients who have served in the armed forces.

Have you ever served in the British Armed Forces?*

Yes

Please provide which part of the forces and base ie RAF Valley.*

Please provide name and addresses of the GP surgery prior to going into the Forces*

Lifestyle

Smoking Status*

Non smoker

Current smoker

Ex-smoker

How many per day?*

Would you like advice on giving up?*

Yes

When did you stop?*

If you drink alcohol, how many days a week do you drink?*

How many drinks do you have on average when you do drink?*

How many times have you forgotten the night before due to drinking?*

How often in the last year have you failed what would normally be expected of you because of drinking?*

Has anyone such as a friend or doctor, or family member said they are worried about your level of drinking?*

Family Information

Please state any serious illnesses that run in your family that you think we should know about and their relation to you*

Next of Kin - Name*

Contact Number*

Address*

Relationship to you*

Emergency contact*

Yes

Can we discuss your medical record with them?*

Yes

Are you up to date with all your vaccinations, or do you think you have missed any?*

Have you had the flu vaccination if you are eligible, If known when was the last date you had it?*

Have you had the pneumococcal vaccination, if known when did you have it?*

Consent*

I agree that I may be contacted from time to time from the Surgery via email and/or SMS text with practice news, advice about my health and or appointments

Please share any Additional information you think we should know. For example if you have any organ transplant preferences or intentions for donating your body to science/medicine, if you have a Living Will or Power of Attorney for health.

Signatures

Signatures*

Patient's signature

Signature on behalf of patient

Consent

I agree for the Practice to contact me using the details provided above.

Electronic Signature (Type your full name here)*

By completing the section above, I hereby sign this form electronically

Update your details

Prescriptions

Online Appointment Booking

Patient Focus Group

Friends & Family Test

Surgery Newsletter

Dental Information

Optician Information

NHS App

Fit Note

Greater Manchester Care Record

Opening Times

Monday
08:00am to 06:30pm
From 6pm-6:30pm calls & medical cover provided by GTD
Tuesday
08:00am to 06:30pm
From 6pm-6:30pm calls & medical cover provided by GTD
Wednesday
08:00am to 01:00pm
From 1pm-6:30pm calls & medical cover provided by GTD
Thursday
08:00am to 06:30pm
From 6pm-6:30pm calls & medical cover provided by GTD
Friday
08:00am to 06:30pm
From 6pm-6:30pm calls & medical cover provided by GTD
Saturday
CLOSED
Sunday
CLOSED

Useful Links

Cottage Lane Surgery

Online Registration