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The form collects patient demographics, identity and residency details, and eligibility information such as Jersey SSD/HIF status. It also gathers home and contact information, address history, emergency contact and next of kin, children under 16 details, previous GP information, insurance and employer details, and includes a declaration covering data protection, confidentiality, privacy statements, and consent for processing and record sharing.",{"@graph":63,"@context":119},[64,80,102],{"@type":65,"itemListElement":66},"BreadcrumbList",[67,71,74,77],{"item":68,"name":69,"@type":70,"position":9},"https://docshare.wps.com","Home","ListItem",{"item":72,"name":10,"@type":70,"position":73},"https://docshare.wps.com/template/",2,{"item":75,"name":36,"@type":70,"position":76},"https://docshare.wps.com/template/forms/",3,{"item":78,"name":59,"@type":70,"position":79},"https://docshare.wps.com/template/patient-registration-form-adult/307407/",4,{"url":78,"name":59,"@type":81,"image":82,"author":87,"headline":59,"publisher":90,"fileFormat":93,"inLanguage":57,"description":61,"dateModified":94,"datePublished":95,"encodingFormat":93,"isAccessibleForFree":96,"interactionStatistic":97},"DigitalDocument",{"url":83,"@type":84,"width":85,"height":86},"https://docshare.wps.com/thumbnails/patient-registration-form-adult/307407.png","ImageObject",442,249,{"name":88,"@type":89},"Aurora","Person",{"url":68,"name":91,"@type":92},"DocShare","Organization","application/pdf","2026-10-23","2026-09-19",true,{"@type":98,"interactionType":99,"userInteractionCount":101},"InteractionCounter",{"@type":100},"ViewAction",10,{"@type":103,"mainEntity":104},"FAQPage",[105,111,115],{"name":106,"@type":107,"acceptedAnswer":108},"Who needs to complete this adult registration form?","Question",{"text":109,"@type":110},"Each adult and young person over the age of 16 must complete an individual patient registration form.","Answer",{"name":112,"@type":107,"acceptedAnswer":113},"What information is required for patient identification and residency?",{"text":114,"@type":110},"The form requests details such as title, name(s), gender identity, date of birth, ethnicity selections, reason for registering, resident since, Jersey SSD identifiers, and whether identification has been confirmed (e.g., passport or driving licence).",{"name":116,"@type":107,"acceptedAnswer":117},"What does the patient declaration include regarding data protection and confidentiality?",{"text":118,"@type":110},"It explains how collected information will be used for healthcare services and practice administration under relevant Data Protection (Jersey) Law provisions, describes sharing with approved healthcare providers for lawful purposes, and includes consent and rights such as opting out of shared medical records.","https://schema.org",{"og:url":78,"og:type":121,"og:title":59,"og:site_name":91,"og:description":61},"article",{"robots":123,"canonical":78},"index,follow",{"doc_id":125,"site_id":56},307407,1790226064,{"code":4,"msg":5,"data":128},{"doc_id":125,"user_id":129,"nickname":88,"user_avatar":130,"doc_module":9,"category_id":35,"category_name":36,"doc_title":59,"doc_description":61,"doc_content":131,"file_id":132,"file_url":133,"file_type":134,"file_size":135,"view_count":101,"is_deleted":4,"is_public":9,"is_downloadable":9,"audit_status":9,"page_count":47,"language":136,"language_code":57,"site_id":56,"html_lang":57,"table_of_contents":137,"faqs":138,"seo_title":139,"seo_description":61,"update_tm":140,"read_time":73},4810365810221,"https://ap-avatar.wpscdn.com/davatar_155a257f0dc6eb9ab79c44ca47cae57d","Castle Quay Medical Practice Patient Registration Form: ADULT  \nIndividual patient registration forms must be completed for each adult and young person over the age of16. Please complete clearly all relevant sections of this registration form.  \nPRIMARY 􀁣  \n\n| 1. Patient Information  |  |  |  |  |\n| --- | --- | --- | --- | --- |\n| Title: | Miss / Mr / Mrs / Ms / Mstr / Mx / | Gender Identity: |  Female  Male  Trans  Other |  |\n| Family Name: |  | Marital Status: |  Single  Married  Civil Partnership\u003Cbr> Separated  Divorced  Other |  |\n| Given Name(s): |  | Ethnicity: Select A and B | A:  White  Black  Asian  Mixed  Other\u003Cbr>B:  British  European  Other |  |\n| Known As: |  | First Language: If not English |  |  |\n| Previous Family Name: |  | Resident Since: Month/Year | / |  |\n| Date of Birth: |  | Reason For Registering with the Practice: |  Transferring from another Jersey GP Practice\u003Cbr> Re-Registering with GP Practice\u003Cbr> New Resident In Jersey |  |\n| Jersey SSD No/Card: | Seen\u003Cbr>By: |  |  |  |\n| Jersey SSD HIF Status:(For Practice to complete) |  HIO  HMA  Private | Identification Confirmed:(Passport / Driving Licence) |  Yes  No | ID Type:\u003Cbr>Seen By: |\n\n\n| 2. Home Address and Contact Information (For ID purposes Utility Bill/Bank Statement or Tax/SSD Notification dated within 3 months is valid)  |  |  |  |  |\n| --- | --- | --- | --- | --- |\n| Current\u003Cbr>Home Address (1): |  | Home Telephone: |  |  |\n|  |  | Work Telephone: |  |  |\n|  |  | Mobile Telephone: |  |  |\n|  |  | Personal Email Address: |  |  |\n| Post-Code: |  | Address Confirmed:\u003Cbr>Dated within 3 months of issue |  Yes  No | Doc. Type:\u003Cbr>Seen By: |\n| Access Information: for impaired patient visits |  |  |  |  |\n\n\n| 3. Previous Home Address (If less than three years at the current home address)  |  |  |  |\n| --- | --- | --- | --- |\n| Previous\u003Cbr>Home Address (2): |  | Previous\u003Cbr>Home Address (3): |  |\n| Date From / To: | / | Date From / To: | / |\n\n\n| 4. Emergency Contact/Next of Kin Information  |  |  |  |\n| --- | --- | --- | --- |\n| Title: | Miss / Mr / Mrs / Ms / Mx / | Home Address & Post-Code:\u003Cbr> Same as Section 2 |  |\n| Family Name: |  |  |  |\n| Given Name(s): |  |  |  |\n| Date of Birth: |  | Home Telephone: |  |\n| Relationship to Patient: |  | Work Telephone: |  |\n| Your Next of Kin: |  Yes  No | Mobile Telephone: |  |\n| Consent for us to Discuss Your Record: |  Yes  No | Your Official Carer: |  Yes  No |\n\n\n| 5. Children Under 16 that you are the Parent or Legal Guardian (Registrations Form to be completed for all those registering with the practice)  |  |  |\n| --- | --- | --- |\n| Child Full Name: |  | Date of Birth: |\n| Child Full Name: |  | Date of Birth: |\n| Child Full Name: |  | Date of Birth: |\n| Child Full Name: |  | Date of Birth: |\n| Child Full Name: |  | Date of Birth: |\n\n\n| 6. Previous/Existing GP Information  |  |  |  |\n| --- | --- | --- | --- |\n| GP Name: |  | Telephone Number: |  |\n| Address: |  |  |  |\n| Reason for Transferring: |  |  |  |\n\n\n| 7. Private Medical Insurance and Current Employer Information (The Patient is responsible for making all claims with their insurer)  |  |\n| --- | --- |\n| Insurance Provider: |  |\n\n\n| 8. Patient Declaration, Confidentiality Agreement, Personal Data Statement and Communication  |  |  |\n| --- | --- | --- |\n| Your Personal Information (Data Protection and Patient Privacy):\u003Cbr>The information collected on this application form will be used by Castle Quay Medical Practcie (hereafter the ‘Practice’) for the purposes of healthcare related services and practice administration. Personal information we hold about you is processed for the purposes of ‘Employment and Social Fields’ (Article 8) ‘Medical Purposes’ (Article 15) and ‘Public Health’ (Article 16) of the Data Protection (Jersey) Law 2018. This may require your personal data including, relevant details of your medical history, to be shared with other approved healthcare providers for the purpose of referrals and for other lawful purposes related to the","cbCaitkXamnNv2Yp","https://ap.wps.com/l/cbCaitkXamnNv2Yp","pdf",285797,"English","# Patient Information\n# Home Address and Contact Information\n# Previous Home Address\n# Emergency Contact/Next of Kin Information\n# Children Under 16\n# Previous/Existing GP Information\n# Private Medical Insurance and Current Employer Information\n# Patient Declaration, Confidentiality Agreement, Personal Data Statement and Communication","[{\"question\":\"Who needs to complete this adult registration form?\",\"answer\":\"Each adult and young person over the age of 16 must complete an individual patient registration form.\"},{\"question\":\"What information is required for patient identification and residency?\",\"answer\":\"The form requests details such as title, name(s), gender identity, date of birth, ethnicity selections, reason for registering, resident since, Jersey SSD identifiers, and whether identification has been confirmed (e.g., passport or driving licence).\"},{\"question\":\"What does the patient declaration include regarding data protection and confidentiality?\",\"answer\":\"It explains how collected information will be used for healthcare services and practice administration under relevant Data Protection (Jersey) Law provisions, describes sharing with approved healthcare providers for lawful purposes, and includes consent and rights such as opting out of shared medical records.\"}]","Patient Registration Form - Adult | PDF",1789848883]