Pine Medical Centre

Fredora Avenue, Hayes, Middlesex, UB4 8RD

Telephone: 020 8432 8569

We're open

CQC Good Rating

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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*

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

No

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

No

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

Identification

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Max. file size: 128 MB.

If available, please upload proof of your address and photo ID.

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

Comments

This field is for validation purposes and should be left unchanged.

67537

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Prescriptions

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Patient Survey

Friends & Family Test

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Opening Times

Monday
08:00am to 06:30pm
Tuesday
08:00am to 06:30pm
Wednesday
08:00am to 06:30pm
Thursday
08:00am to 06:30pm
Friday
08:00am to 06:30pm
Saturday
CLOSED
Sunday
CLOSED

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PATCHS

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Name*

First Last

Date of Birth*

Address*

Phone*

Email*

Smoking Status*

How many per day?*

Name

This field is for validation purposes and should be left unchanged.

95150

Patient Survey

"*" indicates required fields

1Past Experience

2About the Practice

3The Clinicians

In the past 6 months, how easy have you found the following:*

	Very easy	Fairly easy	Not very easy	Very difficult	N/A
Getting through on the phone
Speaking to a doctor on the phone
Speaking to a nurse on the phone
Obtaining test results by phone

Think about the last time you tried to see a doctor fairly quickly. Were you able to see a doctor on the same day or in the next two weekdays that the surgery was open?*

Yes	No	Cant remember

If you weren't able to be seen during the next 2 weekdays, why was that?

There weren't any appointments

Times offered didn't suit

Appointment was with a Dr who I didn't want to see

Only a nurse was free but I wanted to see a Dr

Other

Please let us know the reason:*

How clean do you find the GP Surgery?*

Very clean	Fairly clean	Not very clean	Not at all clean

How helpful do you find the receptionists?*

Very	Fairly	Not very	Not at all

How long after your appointment time do you normally wait to be seen (excluding drop-in clinics)?*

I am normally seen on time	0-15 minutes	15-30 minutes	More than 30 minutes	Cant remember

How satisfied are you with the opening hours at the surgery?*

Very	Fairly	Neither satisfied nor dissatisfied	Quite dissatisfied	Very dissatisfied

How easy is it for you to get an appointment with a GP?*

Very easy	Fairly easy	Not very easy	Not at all easy	Don't know

The last time you saw a GP, how good was the GP at each of the following:*

	Very good	Good	Average	Poor	Very poor
Giving you enough time
Asking about your symptoms
Listening to you
Explaining tests & treatment
Involving you in decisions about your care
Treating you with care and concern
Taking your problems seriously

How easy is it for you to get an appointment with a Nurse?*

Very easy	Fairly easy	Not very easy	Not at all easy	Don't know

The last time you saw a Nurse, how good was the Nurse at each of the following:*

	Very good	Good	Average	Poor	Very poor
Giving you enough time
Asking about your symptoms
Listening to you
Explaining tests & treatment
Involving you in decisions about your care
Treating you with care and concern
Taking your problems seriously

Name

This field is for validation purposes and should be left unchanged.

34841

Friends & Family Test

"*" indicates required fields

We would like you to think about your recent experiences of our service.

Thinking about your recent visit, overall, how was your experience of our service?*

Very good

Good

Neither good nor poor

Poor

Very poor

Don't know

Please can you tell us why you gave your answer?

Comments

This field is for validation purposes and should be left unchanged.

26716

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