Sexual Health Dorset registration form - East :: Dorset HealthCare University NHS Foundation Trust

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

Any previous surnames?

Date of birth (DD/MM/YYYY) Required

What was your gender at birth? Required

What is your gender identity? Required

If you selected other, please describe

What is your sexuality? Required

Are you an Armed Forces veteran? Required

In which country were you born? Required

What is your nationality? Required

What is your ethnic origin? Required

Name and address of GP surgery you attend Required

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

Can we tell your GP if necessary about any treatment you have received at this clinic? Required

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? Required

Can we write to you at this address? Required

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

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

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

Can we email you at this address? (Letters will be encrypted) Required

Do you have any disabilities that we need to be aware of whilst attending the clinic, including any issues that may affect your understanding or ability to read or hear information? Required

If you answered Yes to having a disability, please provide further details

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): Required

Sexual Health Dorset registration form - East

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