Mill Street Surgery Registration Form

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Please fill out the form to the best of your ability, making use of the Guidance Notes prove

Name (True or Preferred) / Preferred Form of Address *

Title: *

Usual/Preferred Form (if your preferred or usual form has access requirements, please give details below)

Contact Information (If a rite is required to summon you to appointments, please give details below or in supporting docs)

Current Address (if preferred, please indicate the boundaries of your range on the map provided) *

Previous GP Name & Address *

Allergies/Intolerances/Aversions *

Elemental Affinity Assessment *

Poor/Fatal

Fair/Not Preferred

Satisfactory/Ambivalent

Very good/Strong Preference

Excellent/Vital

Earth

Water

Air/Aether

Fire

Humour Assessment *

Lifestyle Assessment (Please read the Guidance Notes provided and answer honestly) *

Strongly disagree

Disagree

Neutral

Agree

Strongly agree

I engage in the approporiate levels of activity for my Kith and Kin

My diet closely matches the healthy eating guide for my Kith and Kin

I do not regularly exceed the recommended/safe/legal number of units of Recreational Depressants for my Kith and Kin

I do not regularly exceed the recommended/safe and legal limits of Recreational Stimulants for my Kith and Kin

I do not regularly exceed the recommended/safe and legal limits of Recreational Hallucinogens for my Kith and Kin

Strongly disagree

Disagree

Neutral

Agree

Strongly agree

I engage in the approporiate levels of activity for my Kith and Kin

My diet closely matches the healthy eating guide for my Kith and Kin

I do not regularly exceed the recommended/safe/legal number of units of Recreational Depressants for my Kith and Kin

I do not regularly exceed the recommended/safe and legal limits of Recreational Stimulants for my Kith and Kin

I do not regularly exceed the recommended/safe and legal limits of Recreational Hallucinogens for my Kith and Kin

If you answered Disagree/Strongly Disagree to any of the above, please complete the following section:

Strongly disagree

Disagree

Neutral

Agree

Strongly agree

I have lost time as a result of my recreational indulgences

I am prone to violent outbursts when over-indulging

I have woken up covered in blood that I could not explain

Other people express concerns about my recreational habits

I myself have concerns about my recreational habits

Clear selection

Do you consent to Mill St Surgery keeping an aura sample on file?

Yes

Not at this time

Please indicate your preferences in the event of your unnatural death *

Do Not Resuscitate

Do Not Resurrect

Do Not Permit To Rise

Do Not Contact Next of Kin: see signed consent form 13B

Permit to Rise (I understand this option is entirely at my own risk and may pose a threat to those around me)

Contact Next of Kin: they are responsible for me/for carrying out my wishes

Perform Resurrection Ritual [as detailed in Supplementary Document, within stipulated timeframe]

I'm Probably Not Dead - Take No Action (see Supplementary Documents for details)

Other:

Emergency Contact Information

Submit

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