Adult Patient Registration Form
Full Name
Please type your full name.
Date of Birth
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NHI (if known)
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Your occupation
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Address
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Home Phone
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Mobile
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Email address
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Next of Kin
Please specify your position in the company
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Name of next of kin
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Contact number of next of kin
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Referring doctor
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GP if different from above
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Who is your medical insurer?
Please tell us how big is your company.
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Insurance Number
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Please specify your position in the company
Do you have any medication allergies?
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eg Penicillin, Sulphas
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Do skin tests show any reaction to allergies?
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Do you have any other allergies, eg bee stings etc
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Have you had previous ear, nose or throat surgery?
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Have you had any surgery or serious illnesses?
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Do you have any form of bleeding disorder?
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eg Do you bruise easily or is there a family history of such problems?
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Do you suffer from diabetes, hypertension,
heart disease or lung disease?
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Do you smoke?
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Are you currently taking any medications
or have taken any recently?
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eg drops, sprays, medicines, pills, injections etc
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What is the main reason for seeing Dr Brown?
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If it is tonsillitis or otitis media (glue ear) please submit this form and then fill out the additional questionnaire
   
The captcha is case sensitive - on an ipad it will automatically capatilise the first letter - make sure you turn this off on the keyboard. (*) The captcha is case sensitive - on an ipad it will automatically capatilise the first letter - make sure you turn this off on the keyboard.
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