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The Crown Medical Centre Providing NHS services
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Home > Adult Registration Form (18+)

Adult Registration Form (18+)

Welcome to the Crown Medical Centre. To help us provide you with the best possible service, we would be grateful if you would take the time to answer the following questions. Thank you.

Patient details:
Mobile number or Home phone, both if applicable
Please help us trace your previous medical records by providing us the following information:
Please note, do not leave this blank as we are therefore unable to register you without this information. (Unless N/A)
Please note, do not leave this blank as we are therefore unable to register you without this information. (Unless N/A)
If you are from abroad:
Were you ever registered with an Armed Forces GP?
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.

Footnote: 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.

Next of kin:
Household:
If N/A, please state
Are you a carer?
Marital status:
Ethnicity data:
If not applicable please enter 'N/A'
Family history:
Does anybody in your family have any of the following illnesses?
Women Only:
Medical history:
Please state any on-going illnesses or disabilities or any significant past illnesses, operations or accident and the years they happened or started.
Please list medications that you are taking at the present time and the dosage.
Please state any allergies that you have and the date which they started.
Lifestyle Information:
Weight in kilograms if possible, if other, please specify units
Height in centre meters if possible, if other, please specify units
Alcohol audit:
Vaccination history:

Please give us the date of your last vaccinations

Application for online access to medical record (16+):

To obtain access to your appointments, prescriptions and immunisations via the NHS app, Patient Access or any of the NH approved apps you must sign up for Online Access. Once verified by a member of staff you will be sent your unique pin (linkage key) along with instructions on how to set up your account.

If you wish to access your medical record online including your coded medical problems and lab results please ask the receptionist for the form to complete. These forms will need to be brought into the surgery with two forms of ID (1 photographic and 1 proof of address)

If you wish to have access to the following online services, please tick the things you would like visible:
If you wish to access your medical records online, please understand and agree to each statement below:
Register your Type 1 Opt-out preference:

The data held in your GP medical records is shared with other healthcare professionals for the purposes of your individual care. It is also shared with other organisations to support health and care planning and research.

If yo do not want your personally identifiable patient data to be shared outside of your GP practice for purposes except your own care, you can register an opt-out with your GP practice. This is known as a Type 1 Opt-out.

Type 1 Opt-outs may be discontinued in the future. If this happens then they may be turned into a National Data opt-out. Your GP practice will tell you if this is going to happen and if you need to do anything.

This decision will not affect individual care and you can change your choice at any time.

Your decision
Summary Care Record:

The Crown Medical Centre offers its patients the choice of having a Summary Care Record.

The new NHS Summary Care Record has been introduced to help deliver better and safer care and give you more choice about who you share your healthcare information with.

What is the NHS summary care record?

The summary care record contains basic information about:

- any allergies you may have,

- unexpected reactions to medications

- and any prescriptions you have recently received.

The intentions is to help clinicians in Accident and Emergency Departments and 'Out of Hours' health services to give you safe, timely and effective treatment.

Clinicians will only be allowed to access your record if they are authorised to do so and, even then, only if you give your express permission. You will be asked if healthcare staff can look at your Summary care record every time they need to, unless it is an emergency, for instance if you are unconscious. You can refuse if you think access is unnecessary.

Please tick if you would like a summary care record or not.

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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The Crown Medical Centre

Venture Way, Taunton, TA2 8QY

  • 01823 282151
  • crownmc.contact@nhs.net
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