Additional information                                                       

Are you a carer?                     

 Name of person                                                               date of birth: 
                                                 
 (DO NOT include children unless they have a disability)
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Do you smoke? 	        If yes, how many per day 

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Do you drink alcohol?                

If yes how many units per week 

Please see attached information regarding alcohol units.
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Summary care records
Yes I would like a SCR 		       No I would not like a SCR

Summary Care records only require your name, address, NHS number and date of birth, medicines, allergies and any medicines that make you ill. 
This is a new way of helping should an emergency situation arise, the doctors who treat you in A&E will have access to this information which stops mistakes and could save your life

Patient Panel We have a patient participation group meeting every two months as well as a virtual group, if you would like to join, please leave your contact details with reception 

Name ………………………………………………………

Date of birth ……………………………………………..