Dorset HealthCare :: Sexual Health Dorset registration form

Title *

First name(s) *

Surname *

What name would you prefer used when you are called from the waiting room?

Any previous surnames?

Date of birth *

What was your gender at birth? *

What is your gender identity? *

If other, please describe

What is your sexuality? *

In which country were you born? *

What is your nationality? *

What is your ethnic origin? *

Address of GP surgery you attend *

Would you like to receive a copy of any referral letter or routine follow up letter for a long term condition? *

Can we tell your GP if necessary about any treatment you have received at this clinic? Note: We will not pass on information to your GP without your consent, unless you are diagnosed with a serious infection that requires treatment, and we have been unable to contact you to arrange this. *

Do you consent to our service requesting details of your medical history from your GP if we need to? *

Home address *

Post code *

Can we write to this address? *

Home telephone number (Enter N/A if you do not have a home telephone) *

Can we call you on this number? *

Yes No

Can we leave a message on this number? *

Yes No

Mobile number number (Enter N/A if you do not have a mobile phone) *

Can we call you on this number? *

Yes No

Can we text you on this number? *

Yes No

Can we leave a message on this number? *

Yes No

Email address (Enter N/A if you do not have an email address) *

Can we email you at this address? (letters will be encrypted) *

Please specify *

Do you have any disability or other problem that may affect your understanding or ability to read or hear information? *

I accept I will be responsible ensuring that Sexual Health Dorset has the most up to date home and mobile phone numbers, home and email addresses for me and that if I share my mobile phone with another person my information may become known to other parties. *

Signature (as this is an electronic form, please write your name): *

Sexual Health Dorset registration form - West