nhsgp.net
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109.228.57.37
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Submitted URL: https://7day.nhsgp.net/
Effective URL: https://nhsgp.net/
Submission: On August 06 via api from US — Scanned from DE
Effective URL: https://nhsgp.net/
Submission: On August 06 via api from US — Scanned from DE
Form analysis 20 forms found in the DOM
GET https://nhsgp.net/
<form role="search" method="get" id="searchform" class="searchform" action="https://nhsgp.net/">
<div>
<label class="screen-reader-text" for="s">Search for:</label>
<input type="text" value="" name="s" id="s" placeholder="Search">
<input type="submit" id="searchsubmit" value="Search">
</div>
</form><form autocomplete="off">
<div class="wpsl-input">
<div><label for="wpsl-search-input">
<h2>Find a GP</h2>
<p>Enter a town, city or postcode in England</p>
</label></div>
<input id="wpsl-search-input" type="text" value="" name="wpsl-search-input" placeholder="" aria-required="true" class="pac-target-input" autocomplete="off">
<div class="wpsl-icon-direction"><span></span></div>
</div>
<div class="wpsl-select-wrap">
<div id="wpsl-radius">
<label for="wpsl-radius-dropdown">Search radius</label>
<div class="wpsl-dropdown"><select id="wpsl-radius-dropdown" class="" name="wpsl-radius" style="display: none;">
<option value="10">10 mi</option>
<option value="25">25 mi</option>
<option selected="selected" value="50">50 mi</option>
<option value="100">100 mi</option>
<option value="200">200 mi</option>
<option value="500">500 mi</option>
</select><span data-value="50" class="wpsl-selected-item">50 mi</span>
<div>
<ul>
<li data-value="10">10 mi</li>
<li data-value="25">25 mi</li>
<li data-value="50" class="wpsl-selected-dropdown">50 mi</li>
<li data-value="100">100 mi</li>
<li data-value="200">200 mi</li>
<li data-value="500">500 mi</li>
</ul>
</div>
</div>
</div>
<div id="wpsl-results">
<label for="wpsl-results-dropdown">Results</label>
<div class="wpsl-dropdown"><select id="wpsl-results-dropdown" class="" name="wpsl-results" style="display: none;">
<option selected="selected" value="25">25</option>
<option value="50">50</option>
<option value="75">75</option>
<option value="100">100</option>
</select><span data-value="25" class="wpsl-selected-item">25</span>
<div>
<ul>
<li data-value="25" class="wpsl-selected-dropdown">25</li>
<li data-value="50">50</li>
<li data-value="75">75</li>
<li data-value="100">100</li>
</ul>
</div>
</div>
</div>
</div>
<div class="wpsl-search-btn-wrap"><input id="wpsl-search-btn" type="submit" value="Search"><a id="h-useloc" class="btn black-btn" href="#">Use your location</a></div>
</form>POST /
<form method="post" enctype="multipart/form-data" id="gform_6" action="/" data-formid="6" novalidate="">
<div class="gform-body gform_body">
<div id="gform_fields_6" class="gform_fields top_label form_sublabel_below description_below validation_below">
<div id="field_6_1" class="gfield gfield--type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible"
data-js-reload="field_6_1">
<div class="frm-title">Change of Contact Details</div>
</div>
<div id="field_6_3" class="gfield gfield--type-select gfield--width-third gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible" data-js-reload="field_6_3">
<label class="gfield_label gform-field-label" for="input_6_3">Title<span class="gfield_required"><span class="gfield_required gfield_required_text">(Required)</span></span></label>
<div class="ginput_container ginput_container_select"><select name="input_3" id="input_6_3" class="large gfield_select" aria-required="true" aria-invalid="false">
<option value="Mr">Mr</option>
<option value="Mrs">Mrs</option>
<option value="Miss">Miss</option>
<option value="Ms">Ms</option>
<option value="Dr">Dr</option>
<option value="Prof">Prof</option>
</select></div>
</div>
<div id="field_6_4" class="gfield gfield--type-text gfield--width-third gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible" data-js-reload="field_6_4">
<label class="gfield_label gform-field-label" for="input_6_4">First Name(s)<span class="gfield_required"><span class="gfield_required gfield_required_text">(Required)</span></span></label>
<div class="ginput_container ginput_container_text"><input name="input_4" id="input_6_4" type="text" value="" class="large" aria-required="true" aria-invalid="false"> </div>
</div>
<div id="field_6_5" class="gfield gfield--type-text gfield--width-third gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible" data-js-reload="field_6_5">
<label class="gfield_label gform-field-label" for="input_6_5">Surname:<span class="gfield_required"><span class="gfield_required gfield_required_text">(Required)</span></span></label>
<div class="ginput_container ginput_container_text"><input name="input_5" id="input_6_5" type="text" value="" class="large" aria-required="true" aria-invalid="false"> </div>
</div>
<fieldset id="field_6_6" class="gfield gfield--type-radio gfield--type-choice gfield--width-third gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible"
data-js-reload="field_6_6">
<legend class="gfield_label gform-field-label">Sex<span class="gfield_required"><span class="gfield_required gfield_required_text">(Required)</span></span></legend>
<div class="ginput_container ginput_container_radio">
<div class="gfield_radio" id="input_6_6">
<div class="gchoice gchoice_6_6_0">
<input class="gfield-choice-input" name="input_6" type="radio" value="Female" id="choice_6_6_0" onchange="gformToggleRadioOther( this )">
<label for="choice_6_6_0" id="label_6_6_0" class="gform-field-label gform-field-label--type-inline">Female</label>
</div>
<div class="gchoice gchoice_6_6_1">
<input class="gfield-choice-input" name="input_6" type="radio" value="Male" id="choice_6_6_1" onchange="gformToggleRadioOther( this )">
<label for="choice_6_6_1" id="label_6_6_1" class="gform-field-label gform-field-label--type-inline">Male</label>
</div>
</div>
</div>
</fieldset>
<div id="field_6_7"
class="gfield gfield--type-date gfield--input-type-datepicker gfield--datepicker-default-icon gfield--width-third field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible"
data-js-reload="field_6_7"><label class="gfield_label gform-field-label" for="input_6_7">Date of Birth</label>
<div class="ginput_container ginput_container_date">
<input name="input_7" id="input_6_7" type="text" value="" class="datepicker gform-datepicker dmy datepicker_with_icon gdatepicker_with_icon hasDatepicker initialized" placeholder="dd/mm/yyyy" aria-describedby="input_6_7_date_format"
aria-invalid="false"><img class="ui-datepicker-trigger" src="https://nhsgp.net/wp-content/plugins/gravityforms/images/datepicker/datepicker.svg" alt="Select date" title="Select date">
<span id="input_6_7_date_format" class="screen-reader-text">DD slash MM slash YYYY</span>
</div>
<input type="hidden" id="gforms_calendar_icon_input_6_7" class="gform_hidden" value="https://nhsgp.net/wp-content/plugins/gravityforms/images/datepicker/datepicker.svg">
</div>
<div id="field_6_8" class="gfield gfield--type-text gfield--width-third field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible" data-js-reload="field_6_8"><label
class="gfield_label gform-field-label" for="input_6_8">Previous Surname</label>
<div class="ginput_container ginput_container_text"><input name="input_8" id="input_6_8" type="text" value="" class="large" aria-invalid="false"> </div>
</div>
<div id="field_6_9" class="gfield gfield--type-text gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible" data-js-reload="field_6_9"><label
class="gfield_label gform-field-label" for="input_6_9">NHS No</label>
<div class="ginput_container ginput_container_text"><input name="input_9" id="input_6_9" type="text" value="" class="large" aria-invalid="false"> </div>
</div>
<div id="field_6_10" class="gfield gfield--type-email gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible" data-js-reload="field_6_10">
<label class="gfield_label gform-field-label" for="input_6_10">Email:<span class="gfield_required"><span class="gfield_required gfield_required_text">(Required)</span></span></label>
<div class="ginput_container ginput_container_email">
<input name="input_10" id="input_6_10" type="email" value="" class="large" aria-required="true" aria-invalid="false">
</div>
</div>
<div id="field_6_11" class="gfield gfield--type-textarea gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible" data-js-reload="field_6_11"><label
class="gfield_label gform-field-label" for="input_6_11">Old Address</label>
<div class="ginput_container ginput_container_textarea"><textarea name="input_11" id="input_6_11" class="textarea small" aria-invalid="false" rows="10" cols="50"></textarea></div>
</div>
<div id="field_6_12" class="gfield gfield--type-text gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible" data-js-reload="field_6_12">
<label class="gfield_label gform-field-label" for="input_6_12">Old Postcode<span class="gfield_required"><span class="gfield_required gfield_required_text">(Required)</span></span></label>
<div class="ginput_container ginput_container_text"><input name="input_12" id="input_6_12" type="text" value="" class="large" aria-required="true" aria-invalid="false"> </div>
</div>
<div id="field_6_13" class="gfield gfield--type-phone gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible" data-js-reload="field_6_13">
<label class="gfield_label gform-field-label" for="input_6_13">Old Home Tel<span class="gfield_required"><span class="gfield_required gfield_required_text">(Required)</span></span></label>
<div class="ginput_container ginput_container_phone"><input name="input_13" id="input_6_13" type="tel" value="" class="large" aria-required="true" aria-invalid="false"></div>
</div>
<div id="field_6_14" class="gfield gfield--type-textarea gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible"
data-js-reload="field_6_14"><label class="gfield_label gform-field-label" for="input_6_14">New Address<span class="gfield_required"><span class="gfield_required gfield_required_text">(Required)</span></span></label>
<div class="ginput_container ginput_container_textarea"><textarea name="input_14" id="input_6_14" class="textarea small"
placeholder="Note: If your new address falls outside of our catchment area, you will need to register with a new GP and we will be contacting you regarding this matter." aria-required="true" aria-invalid="false" rows="10"
cols="50"></textarea></div>
</div>
<div id="field_6_15" class="gfield gfield--type-text gfield--width-quarter field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible" data-js-reload="field_6_15"><label
class="gfield_label gform-field-label" for="input_6_15">New Postcode</label>
<div class="ginput_container ginput_container_text"><input name="input_15" id="input_6_15" type="text" value="" class="large" aria-invalid="false"> </div>
</div>
<div id="field_6_16" class="gfield gfield--type-phone gfield--width-quarter gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible"
data-js-reload="field_6_16"><label class="gfield_label gform-field-label" for="input_6_16">New Tel<span class="gfield_required"><span class="gfield_required gfield_required_text">(Required)</span></span></label>
<div class="ginput_container ginput_container_phone"><input name="input_16" id="input_6_16" type="tel" value="" class="large" aria-required="true" aria-invalid="false"></div>
</div>
<div id="field_6_17" class="gfield gfield--type-phone gfield--width-quarter field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible" data-js-reload="field_6_17"><label
class="gfield_label gform-field-label" for="input_6_17">Mobile</label>
<div class="ginput_container ginput_container_phone"><input name="input_17" id="input_6_17" type="tel" value="" class="large" aria-invalid="false"></div>
</div>
<div id="field_6_18" class="gfield gfield--type-phone gfield--width-quarter field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible" data-js-reload="field_6_18"><label
class="gfield_label gform-field-label" for="input_6_18">Work Tel</label>
<div class="ginput_container ginput_container_phone"><input name="input_18" id="input_6_18" type="tel" value="" class="large" aria-invalid="false"></div>
</div>
<fieldset id="field_6_19" class="gfield gfield--type-radio gfield--type-choice gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible"
data-js-reload="field_6_19">
<legend class="gfield_label gform-field-label">Are you a student?<span class="gfield_required"><span class="gfield_required gfield_required_text">(Required)</span></span></legend>
<div class="ginput_container ginput_container_radio">
<div class="gfield_radio" id="input_6_19">
<div class="gchoice gchoice_6_19_0">
<input class="gfield-choice-input" name="input_19" type="radio" value="I am NOT a student" id="choice_6_19_0" onchange="gformToggleRadioOther( this )">
<label for="choice_6_19_0" id="label_6_19_0" class="gform-field-label gform-field-label--type-inline">I am NOT a student</label>
</div>
<div class="gchoice gchoice_6_19_1">
<input class="gfield-choice-input" name="input_19" type="radio" value="I AM a student" id="choice_6_19_1" onchange="gformToggleRadioOther( this )">
<label for="choice_6_19_1" id="label_6_19_1" class="gform-field-label gform-field-label--type-inline">I AM a student</label>
</div>
</div>
</div>
</fieldset>
<div id="field_6_20" class="gfield gfield--type-textarea gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible" data-js-reload="field_6_20"><label
class="gfield_label gform-field-label" for="input_6_20">Other members of your family requiring a change of address (if registered here)</label>
<div class="ginput_container ginput_container_textarea"><textarea name="input_20" id="input_6_20" class="textarea small" placeholder="Include full Name(s) & Telephone Number(s)" aria-invalid="false" rows="10" cols="50"></textarea></div>
</div>
</div>
</div>
<div class="gform_footer top_label"> <input type="submit" id="gform_submit_button_6" class="gform_button button" value="Send"
onclick="if(window["gf_submitting_6"]){return false;} if( !jQuery("#gform_6")[0].checkValidity || jQuery("#gform_6")[0].checkValidity()){window["gf_submitting_6"]=true;} "
onkeypress="if( event.keyCode == 13 ){ if(window["gf_submitting_6"]){return false;} if( !jQuery("#gform_6")[0].checkValidity || jQuery("#gform_6")[0].checkValidity()){window["gf_submitting_6"]=true;} jQuery("#gform_6").trigger("submit",[true]); }">
<input type="hidden" class="gform_hidden" name="is_submit_6" value="1">
<input type="hidden" class="gform_hidden" name="gform_submit" value="6">
<input type="hidden" class="gform_hidden" name="gform_unique_id" value="">
<input type="hidden" class="gform_hidden" name="state_6"
value="WyJ7XCI2XCI6W1wiNjg1YTcwYWQ0OWRjMzRjMDQ1OWUyZDRlM2Y2NGM0ZDlcIixcIjk0NzUwNmMxNTJlZWRiMWFjOWRkMWE1OGI1YmRmMTc1XCJdLFwiMTlcIjpbXCI2NDM1MzdkNGE3ZDFjMzcyNDg5YWMxYmQ5YzRmNzcyNFwiLFwiOTIyMjFiOTJhNDNlY2RhZTVkMDVlZTBmZDI4Mjc4YzNcIl19IiwiZDk1NjcxOGI4MmU4MGExYTdkOWQ5ZWExZTRiZjVhMjYiXQ==">
<input type="hidden" class="gform_hidden" name="gform_target_page_number_6" id="gform_target_page_number_6" value="0">
<input type="hidden" class="gform_hidden" name="gform_source_page_number_6" id="gform_source_page_number_6" value="1">
<input type="hidden" name="gform_field_values" value="">
</div>
</form>POST /
<form method="post" enctype="multipart/form-data" id="gform_9" action="/" data-formid="9" novalidate="">
<div class="gform-body gform_body">
<div id="gform_fields_9" class="gform_fields top_label form_sublabel_below description_below validation_below">
<div id="field_9_1" class="gfield gfield--type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible"
data-js-reload="field_9_1">
<div class="frm-title">Comments and Suggestions Form</div>
<div class="frm-desc">This is the easiest way to make a complaint or leave a comment for us.</div>
</div>
<div id="field_9_21"
class="gfield gfield--type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible"
data-js-reload="field_9_21">
<div class="frm-info">
<h5> What kind of comment would you like to send? Remember this form is not for medical matters. </h5>
</div>
</div>
<fieldset id="field_9_6" class="gfield gfield--type-radio gfield--type-choice gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible" data-js-reload="field_9_6">
<legend class="gfield_label gform-field-label">Your comment is:</legend>
<div class="ginput_container ginput_container_radio">
<div class="gfield_radio" id="input_9_6">
<div class="gchoice gchoice_9_6_0">
<input class="gfield-choice-input" name="input_6" type="radio" value="A suggestion" id="choice_9_6_0" onchange="gformToggleRadioOther( this )">
<label for="choice_9_6_0" id="label_9_6_0" class="gform-field-label gform-field-label--type-inline">A suggestion</label>
</div>
<div class="gchoice gchoice_9_6_1">
<input class="gfield-choice-input" name="input_6" type="radio" value="Praise" id="choice_9_6_1" onchange="gformToggleRadioOther( this )">
<label for="choice_9_6_1" id="label_9_6_1" class="gform-field-label gform-field-label--type-inline">Praise</label>
</div>
<div class="gchoice gchoice_9_6_2">
<input class="gfield-choice-input" name="input_6" type="radio" value="Regarding a problem" id="choice_9_6_2" onchange="gformToggleRadioOther( this )">
<label for="choice_9_6_2" id="label_9_6_2" class="gform-field-label gform-field-label--type-inline">Regarding a problem</label>
</div>
<div class="gchoice gchoice_9_6_3">
<input class="gfield-choice-input" name="input_6" type="radio" value="Other" id="choice_9_6_3" onchange="gformToggleRadioOther( this )">
<label for="choice_9_6_3" id="label_9_6_3" class="gform-field-label gform-field-label--type-inline">Other</label>
</div>
</div>
</div>
</fieldset>
<div id="field_9_11" class="gfield gfield--type-textarea gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible" data-js-reload="field_9_11"><label
class="gfield_label gform-field-label" for="input_9_11">What would you like to say? Enter your comments in the space below</label>
<div class="ginput_container ginput_container_textarea"><textarea name="input_11" id="input_9_11" class="textarea small" aria-invalid="false" rows="10" cols="50"></textarea></div>
</div>
<div id="field_9_22"
class="gfield gfield--type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible"
data-js-reload="field_9_22">
<h5>Your contact details </h5>
</div>
<div id="field_9_12" class="gfield gfield--type-text gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible" data-js-reload="field_9_12"><label
class="gfield_label gform-field-label" for="input_9_12">Your name:</label>
<div class="ginput_container ginput_container_text"><input name="input_12" id="input_9_12" type="text" value="" class="large" aria-invalid="false"> </div>
</div>
<div id="field_9_23" class="gfield gfield--type-email gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible" data-js-reload="field_9_23"><label
class="gfield_label gform-field-label" for="input_9_23">Your email:</label>
<div class="ginput_container ginput_container_email">
<input name="input_23" id="input_9_23" type="email" value="" class="large" aria-invalid="false">
</div>
</div>
<div id="field_9_17" class="gfield gfield--type-phone gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible" data-js-reload="field_9_17"><label
class="gfield_label gform-field-label" for="input_9_17">Your telephone number:</label>
<div class="ginput_container ginput_container_phone"><input name="input_17" id="input_9_17" type="tel" value="" class="large" aria-invalid="false"></div>
</div>
<fieldset id="field_9_25" class="gfield gfield--type-checkbox gfield--type-choice gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible"
data-js-reload="field_9_25">
<legend class="gfield_label gform-field-label gfield_label_before_complex">Do you agree to be contacted regarding this matter?<span class="gfield_required"><span class="gfield_required gfield_required_text">(Required)</span></span></legend>
<div class="ginput_container ginput_container_checkbox">
<div class="gfield_checkbox" id="input_9_25">
<div class="gchoice gchoice_9_25_1">
<input class="gfield-choice-input" name="input_25.1" type="checkbox" value="Yes, I agree that the practice may contact me regarding this matter" id="choice_9_25_1">
<label for="choice_9_25_1" id="label_9_25_1" class="gform-field-label gform-field-label--type-inline">Yes, I agree that the practice may contact me regarding this matter</label>
</div>
</div>
</div>
</fieldset>
</div>
</div>
<div class="gform_footer top_label"> <input type="submit" id="gform_submit_button_9" class="gform_button button" value="Send"
onclick="if(window["gf_submitting_9"]){return false;} if( !jQuery("#gform_9")[0].checkValidity || jQuery("#gform_9")[0].checkValidity()){window["gf_submitting_9"]=true;} "
onkeypress="if( event.keyCode == 13 ){ if(window["gf_submitting_9"]){return false;} if( !jQuery("#gform_9")[0].checkValidity || jQuery("#gform_9")[0].checkValidity()){window["gf_submitting_9"]=true;} jQuery("#gform_9").trigger("submit",[true]); }">
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</form>POST /
<form method="post" enctype="multipart/form-data" id="gform_16" action="/" data-formid="16" novalidate="">
<div class="gform-body gform_body">
<div id="gform_fields_16" class="gform_fields top_label form_sublabel_below description_below validation_below">
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data-js-reload="field_16_1">
<div class="frm-title">Requesting Fit Note (Med3)</div>
<div class="frm-desc">The more information you put in this form, the more opportunity we have to help you with your Fit note request</div>
</div>
<div id="field_16_3"
class="gfield gfield--type-html gfield--width-full bold-text gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible"
data-js-reload="field_16_3">Your details: </div>
<div id="field_16_4" class="gfield gfield--type-select gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible" data-js-reload="field_16_4"><label
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<div class="ginput_container ginput_container_select"><select name="input_4" id="input_16_4" class="large gfield_select" aria-invalid="false">
<option value="Mr.">Mr.</option>
<option value="Mrs.">Mrs.</option>
<option value="Miss.">Miss.</option>
<option value="Ms.">Ms.</option>
</select></div>
</div>
<div id="field_16_5"
class="gfield gfield--type-date gfield--input-type-datepicker gfield--datepicker-default-icon gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible"
data-js-reload="field_16_5"><label class="gfield_label gform-field-label" for="input_16_5">Date of birth:<span class="gfield_required"><span class="gfield_required gfield_required_text">(Required)</span></span></label>
<div class="ginput_container ginput_container_date">
<input name="input_5" id="input_16_5" type="text" value="" class="datepicker gform-datepicker dmy datepicker_with_icon gdatepicker_with_icon hasDatepicker initialized" placeholder="dd/mm/yyyy" aria-describedby="input_16_5_date_format"
aria-invalid="false" aria-required="true"><img class="ui-datepicker-trigger" src="https://nhsgp.net/wp-content/plugins/gravityforms/images/datepicker/datepicker.svg" alt="Select date" title="Select date">
<span id="input_16_5_date_format" class="screen-reader-text">DD slash MM slash YYYY</span>
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<input type="hidden" id="gforms_calendar_icon_input_16_5" class="gform_hidden" value="https://nhsgp.net/wp-content/plugins/gravityforms/images/datepicker/datepicker.svg">
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<div id="field_16_6" class="gfield gfield--type-text gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible" data-js-reload="field_16_6">
<label class="gfield_label gform-field-label" for="input_16_6">First name:<span class="gfield_required"><span class="gfield_required gfield_required_text">(Required)</span></span></label>
<div class="ginput_container ginput_container_text"><input name="input_6" id="input_16_6" type="text" value="" class="large" aria-required="true" aria-invalid="false"> </div>
</div>
<div id="field_16_7" class="gfield gfield--type-text gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible" data-js-reload="field_16_7">
<label class="gfield_label gform-field-label" for="input_16_7">Surname:<span class="gfield_required"><span class="gfield_required gfield_required_text">(Required)</span></span></label>
<div class="ginput_container ginput_container_text"><input name="input_7" id="input_16_7" type="text" value="" class="large" aria-required="true" aria-invalid="false"> </div>
</div>
<div id="field_16_8" class="gfield gfield--type-text gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible" data-js-reload="field_16_8">
<label class="gfield_label gform-field-label" for="input_16_8">Email:<span class="gfield_required"><span class="gfield_required gfield_required_text">(Required)</span></span></label>
<div class="ginput_container ginput_container_text"><input name="input_8" id="input_16_8" type="text" value="" class="large" aria-required="true" aria-invalid="false"> </div>
</div>
<div id="field_16_9" class="gfield gfield--type-text gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible" data-js-reload="field_16_9">
<label class="gfield_label gform-field-label" for="input_16_9">Postcode:<span class="gfield_required"><span class="gfield_required gfield_required_text">(Required)</span></span></label>
<div class="ginput_container ginput_container_text"><input name="input_9" id="input_16_9" type="text" value="" class="large" aria-required="true" aria-invalid="false"> </div>
</div>
<div id="field_16_10" class="gfield gfield--type-phone gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible"
data-js-reload="field_16_10"><label class="gfield_label gform-field-label" for="input_16_10">Telephone:<span class="gfield_required"><span class="gfield_required gfield_required_text">(Required)</span></span></label>
<div class="ginput_container ginput_container_phone"><input name="input_10" id="input_16_10" type="tel" value="" class="large" aria-required="true" aria-invalid="false"></div>
</div>
<div id="field_16_11"
class="gfield gfield--type-html gfield--width-full bold-text gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible"
data-js-reload="field_16_11">The next part of this form, is you opportunity to clarify why you are asking for a fit note.</div>
<div id="field_16_12" class="gfield gfield--type-text gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible"
data-js-reload="field_16_12"><label class="gfield_label gform-field-label" for="input_16_12">Medical reason for sick note request:<span class="gfield_required"><span
class="gfield_required gfield_required_text">(Required)</span></span></label>
<div class="ginput_container ginput_container_text"><input name="input_12" id="input_16_12" type="text" value="" class="large" aria-required="true" aria-invalid="false"> </div>
</div>
<div id="field_16_13"
class="gfield gfield--type-date gfield--input-type-datepicker gfield--datepicker-default-icon gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible"
data-js-reload="field_16_13"><label class="gfield_label gform-field-label" for="input_16_13">Proposed Fit Note Start Date<span class="gfield_required"><span class="gfield_required gfield_required_text">(Required)</span></span></label>
<div class="ginput_container ginput_container_date">
<input name="input_13" id="input_16_13" type="text" value="" class="datepicker gform-datepicker dmy datepicker_with_icon gdatepicker_with_icon hasDatepicker initialized" placeholder="dd/mm/yyyy" aria-describedby="input_16_13_date_format"
aria-invalid="false" aria-required="true"><img class="ui-datepicker-trigger" src="https://nhsgp.net/wp-content/plugins/gravityforms/images/datepicker/datepicker.svg" alt="Select date" title="Select date">
<span id="input_16_13_date_format" class="screen-reader-text">DD slash MM slash YYYY</span>
</div>
<input type="hidden" id="gforms_calendar_icon_input_16_13" class="gform_hidden" value="https://nhsgp.net/wp-content/plugins/gravityforms/images/datepicker/datepicker.svg">
</div>
<div id="field_16_14"
class="gfield gfield--type-date gfield--input-type-datepicker gfield--datepicker-default-icon gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible"
data-js-reload="field_16_14"><label class="gfield_label gform-field-label" for="input_16_14">Proposed Fit Note End Date<span class="gfield_required"><span class="gfield_required gfield_required_text">(Required)</span></span></label>
<div class="ginput_container ginput_container_date">
<input name="input_14" id="input_16_14" type="text" value="" class="datepicker gform-datepicker dmy datepicker_with_icon gdatepicker_with_icon hasDatepicker initialized" placeholder="dd/mm/yyyy" aria-describedby="input_16_14_date_format"
aria-invalid="false" aria-required="true"><img class="ui-datepicker-trigger" src="https://nhsgp.net/wp-content/plugins/gravityforms/images/datepicker/datepicker.svg" alt="Select date" title="Select date">
<span id="input_16_14_date_format" class="screen-reader-text">DD slash MM slash YYYY</span>
</div>
<input type="hidden" id="gforms_calendar_icon_input_16_14" class="gform_hidden" value="https://nhsgp.net/wp-content/plugins/gravityforms/images/datepicker/datepicker.svg">
</div>
<div id="field_16_15" class="gfield gfield--type-text gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible"
data-js-reload="field_16_15"><label class="gfield_label gform-field-label" for="input_16_15">Why do you feel that your medical condition stops you from working?<span class="gfield_required"><span
class="gfield_required gfield_required_text">(Required)</span></span></label>
<div class="ginput_container ginput_container_text"><input name="input_15" id="input_16_15" type="text" value="" class="large" aria-required="true" aria-invalid="false"> </div>
</div>
<div id="field_16_16" class="gfield gfield--type-text gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible"
data-js-reload="field_16_16"><label class="gfield_label gform-field-label" for="input_16_16">What investigations/treatment have you been doing/taking for the above medical condition?<span class="gfield_required"><span
class="gfield_required gfield_required_text">(Required)</span></span></label>
<div class="ginput_container ginput_container_text"><input name="input_16" id="input_16_16" type="text" value="" class="large" aria-required="true" aria-invalid="false"> </div>
</div>
<div id="field_16_17" class="gfield gfield--type-text gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible"
data-js-reload="field_16_17"><label class="gfield_label gform-field-label" for="input_16_17">What evidence do you have from your specialist specifying that you cannot work?<span class="gfield_required"><span
class="gfield_required gfield_required_text">(Required)</span></span></label>
<div class="ginput_container ginput_container_text"><input name="input_17" id="input_16_17" type="text" value="" class="large" aria-required="true" aria-invalid="false"> </div>
</div>
<div id="field_16_18"
class="gfield gfield--type-html gfield--width-full bold-text gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible"
data-js-reload="field_16_18">Please email any supporting documents to docman.e84066@nhs.net</div>
<div id="field_16_19" class="gfield gfield--type-captcha gfield--width-full field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible" data-js-reload="field_16_19"><label
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<div style="width: 304px; height: 78px;">
<div><iframe title="reCAPTCHA" width="304" height="78" role="presentation" name="a-5wumk3ye52zb" frameborder="0" scrolling="no"
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</div><textarea id="g-recaptcha-response" name="g-recaptcha-response" class="g-recaptcha-response"
style="width: 250px; height: 40px; border: 1px solid rgb(193, 193, 193); margin: 10px 25px; padding: 0px; resize: none; display: none;"></textarea>
</div>
</div>
</div>
</div>
</div>
<div class="gform_footer top_label"> <input type="submit" id="gform_submit_button_16" class="gform_button button" value="Submit"
onclick="if(window["gf_submitting_16"]){return false;} if( !jQuery("#gform_16")[0].checkValidity || jQuery("#gform_16")[0].checkValidity()){window["gf_submitting_16"]=true;} "
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<input type="hidden" class="gform_hidden" name="gform_submit" value="16">
<input type="hidden" class="gform_hidden" name="gform_unique_id" value="">
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<input type="hidden" name="gform_field_values" value="">
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</form>POST /
<form method="post" enctype="multipart/form-data" id="gform_2" action="/" data-formid="2" novalidate="">
<div class="gform-body gform_body">
<div id="gform_fields_2" class="gform_fields top_label form_sublabel_below description_below validation_below">
<div id="field_2_1" class="gfield gfield--type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible"
data-js-reload="field_2_1">
<div class="frm-title">Alcohol Questionnaire for Adults</div>
<div class="frm-desc">This is the easiest way to make a complaint or leave a comment for us.</div>
<div class="fr-name">Your contact details</div>
</div>
<div id="field_2_8" class="gfield gfield--type-select gfield--width-third field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible" data-js-reload="field_2_8"><label
class="gfield_label gform-field-label" for="input_2_8">Title:</label>
<div class="ginput_container ginput_container_select"><select name="input_8" id="input_2_8" class="large gfield_select" aria-invalid="false">
<option value="Mr.">Mr.</option>
<option value="Mrs.">Mrs.</option>
<option value="Miss.">Miss.</option>
<option value="Ms.">Ms.</option>
</select></div>
</div>
<div id="field_2_5" class="gfield gfield--type-text gfield--width-third gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible" data-js-reload="field_2_5">
<label class="gfield_label gform-field-label" for="input_2_5">First name:<span class="gfield_required"><span class="gfield_required gfield_required_text">(Required)</span></span></label>
<div class="ginput_container ginput_container_text"><input name="input_5" id="input_2_5" type="text" value="" class="large" aria-required="true" aria-invalid="false"> </div>
</div>
<div id="field_2_7" class="gfield gfield--type-text gfield--width-third gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible" data-js-reload="field_2_7">
<label class="gfield_label gform-field-label" for="input_2_7">Last name:<span class="gfield_required"><span class="gfield_required gfield_required_text">(Required)</span></span></label>
<div class="ginput_container ginput_container_text"><input name="input_7" id="input_2_7" type="text" value="" class="large" aria-required="true" aria-invalid="false"> </div>
</div>
<div id="field_2_9"
class="gfield gfield--type-date gfield--input-type-datepicker gfield--datepicker-default-icon gfield--width-third gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible"
data-js-reload="field_2_9"><label class="gfield_label gform-field-label" for="input_2_9">Date of birth:<span class="gfield_required"><span class="gfield_required gfield_required_text">(Required)</span></span></label>
<div class="ginput_container ginput_container_date">
<input name="input_9" id="input_2_9" type="text" value="" class="datepicker gform-datepicker dmy datepicker_with_icon gdatepicker_with_icon hasDatepicker initialized" placeholder="dd/mm/yyyy" aria-describedby="input_2_9_date_format"
aria-invalid="false" aria-required="true"><img class="ui-datepicker-trigger" src="https://nhsgp.net/wp-content/plugins/gravityforms/images/datepicker/datepicker.svg" alt="Select date" title="Select date">
<span id="input_2_9_date_format" class="screen-reader-text">DD slash MM slash YYYY</span>
</div>
<input type="hidden" id="gforms_calendar_icon_input_2_9" class="gform_hidden" value="https://nhsgp.net/wp-content/plugins/gravityforms/images/datepicker/datepicker.svg">
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<div id="field_2_10" class="gfield gfield--type-email gfield--width-two-thirds gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible"
data-js-reload="field_2_10"><label class="gfield_label gform-field-label" for="input_2_10">Email<span class="gfield_required"><span class="gfield_required gfield_required_text">(Required)</span></span></label>
<div class="ginput_container ginput_container_email">
<input name="input_10" id="input_2_10" type="email" value="" class="large" aria-required="true" aria-invalid="false">
</div>
</div>
<div id="field_2_11" class="gfield gfield--type-phone gfield--width-third gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible"
data-js-reload="field_2_11"><label class="gfield_label gform-field-label" for="input_2_11">Home phone:<span class="gfield_required"><span class="gfield_required gfield_required_text">(Required)</span></span></label>
<div class="ginput_container ginput_container_phone"><input name="input_11" id="input_2_11" type="tel" value="" class="large" aria-required="true" aria-invalid="false"></div>
</div>
<div id="field_2_12" class="gfield gfield--type-phone gfield--width-third gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible"
data-js-reload="field_2_12"><label class="gfield_label gform-field-label" for="input_2_12">Work phone:<span class="gfield_required"><span class="gfield_required gfield_required_text">(Required)</span></span></label>
<div class="ginput_container ginput_container_phone"><input name="input_12" id="input_2_12" type="tel" value="" class="large" aria-required="true" aria-invalid="false"></div>
</div>
<div id="field_2_13" class="gfield gfield--type-phone gfield--width-third gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible"
data-js-reload="field_2_13"><label class="gfield_label gform-field-label" for="input_2_13">Mobile phone:<span class="gfield_required"><span class="gfield_required gfield_required_text">(Required)</span></span></label>
<div class="ginput_container ginput_container_phone"><input name="input_13" id="input_2_13" type="tel" value="" class="large" aria-required="true" aria-invalid="false"></div>
</div>
<div id="field_2_14" class="gfield gfield--type-textarea gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible"
data-js-reload="field_2_14"><label class="gfield_label gform-field-label" for="input_2_14">Home address:<span class="gfield_required"><span class="gfield_required gfield_required_text">(Required)</span></span></label>
<div class="ginput_container ginput_container_textarea"><textarea name="input_14" id="input_2_14" class="textarea small" aria-required="true" aria-invalid="false" rows="10" cols="50"></textarea></div>
</div>
<div id="field_2_15"
class="gfield gfield--type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible"
data-js-reload="field_2_15">
<div class="md-title">Alcohol</div>
</div>
<div id="field_2_16" class="gfield gfield--type-select gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible" data-js-reload="field_2_16"><label
class="gfield_label gform-field-label" for="input_2_16">How often do you have a drink containing alcohol?</label>
<div class="ginput_container ginput_container_select"><select name="input_16" id="input_2_16" class="large gfield_select" aria-invalid="false">
<option value="Never">Never</option>
<option value="Monthky Or Less">Monthky Or Less</option>
<option value="2-4 times a month">2-4 times a month</option>
<option value="2-3 times a week">2-3 times a week</option>
<option value="4 or more times a week">4 or more times a week</option>
</select></div>
</div>
<div id="field_2_17" class="gfield gfield--type-select gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible" data-js-reload="field_2_17"><label
class="gfield_label gform-field-label" for="input_2_17">How many standard drinks containing alcohol do you have on a typical day?</label>
<div class="ginput_container ginput_container_select"><select name="input_17" id="input_2_17" class="large gfield_select" aria-invalid="false">
<option value="1 or 2">1 or 2</option>
<option value="3 or 4">3 or 4</option>
<option value="5 or 6">5 or 6</option>
<option value="7 or 8">7 or 8</option>
<option value="10 or more">10 or more</option>
</select></div>
</div>
<div id="field_2_18" class="gfield gfield--type-select gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible" data-js-reload="field_2_18"><label
class="gfield_label gform-field-label" for="input_2_18">MEN: How often do you have EIGHT or more drinks on one occasion?</label>
<div class="ginput_container ginput_container_select"><select name="input_18" id="input_2_18" class="large gfield_select" aria-invalid="false">
<option value="Never">Never</option>
<option value="Less than Monthly">Less than Monthly</option>
<option value="Monthly">Monthly</option>
<option value="Weekly">Weekly</option>
<option value="Daily">Daily</option>
</select></div>
</div>
<div id="field_2_20" class="gfield gfield--type-select gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible" data-js-reload="field_2_20"><label
class="gfield_label gform-field-label" for="input_2_20">WOMEN: How often do you have SIX or more drinks on one occasion?</label>
<div class="ginput_container ginput_container_select"><select name="input_20" id="input_2_20" class="large gfield_select" aria-invalid="false">
<option value="Never">Never</option>
<option value="Less than Monthly">Less than Monthly</option>
<option value="Monthly">Monthly</option>
<option value="Weekly">Weekly</option>
<option value="Daily">Daily</option>
</select></div>
</div>
<div id="field_2_21"
class="gfield gfield--type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible"
data-js-reload="field_2_21"><small>1 drink = 1/2 pint of beer or 1 glass of wine or 1 single spirits.<br> 1 unit of alcohol = 10cc of alcohol. So, a small glass (125cc) of 12% wine is 12.5 * 0.12 = 1.5 units.</small></div>
</div>
</div>
<div class="gform_footer top_label"> <input type="submit" id="gform_submit_button_2" class="gform_button button" value="Submit"
onclick="if(window["gf_submitting_2"]){return false;} if( !jQuery("#gform_2")[0].checkValidity || jQuery("#gform_2")[0].checkValidity()){window["gf_submitting_2"]=true;} "
onkeypress="if( event.keyCode == 13 ){ if(window["gf_submitting_2"]){return false;} if( !jQuery("#gform_2")[0].checkValidity || jQuery("#gform_2")[0].checkValidity()){window["gf_submitting_2"]=true;} jQuery("#gform_2").trigger("submit",[true]); }">
<input type="hidden" class="gform_hidden" name="is_submit_2" value="1">
<input type="hidden" class="gform_hidden" name="gform_submit" value="2">
<input type="hidden" class="gform_hidden" name="gform_unique_id" value="">
<input type="hidden" class="gform_hidden" name="state_2" value="WyJbXSIsIjIyZDg5ZTVjZWRhYTEzY2EyMjdhNzkzNTllOWFkYTUxIl0=">
<input type="hidden" class="gform_hidden" name="gform_target_page_number_2" id="gform_target_page_number_2" value="0">
<input type="hidden" class="gform_hidden" name="gform_source_page_number_2" id="gform_source_page_number_2" value="1">
<input type="hidden" name="gform_field_values" value="">
</div>
</form>POST /
<form method="post" enctype="multipart/form-data" id="gform_3" action="/" data-formid="3" novalidate="">
<div class="gform-body gform_body">
<div id="gform_fields_3" class="gform_fields top_label form_sublabel_below description_below validation_below">
<div id="field_3_1" class="gfield gfield--type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible"
data-js-reload="field_3_1">
<div class="frm-title">Application to Register with a General Medical Practitioner</div>
<div class="frm-info">
<h5>Patient's Details</h5>
<p>Please complete the text boxes and tick where appropriate</p>
</div>
</div>
<div id="field_3_7" class="gfield gfield--type-select gfield--width-quarter input-style field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible" data-js-reload="field_3_7"><label
class="gfield_label gform-field-label" for="input_3_7">Title:</label>
<div class="ginput_container ginput_container_select"><select name="input_7" id="input_3_7" class="large gfield_select" aria-invalid="false">
<option value="Mr.">Mr.</option>
<option value="Mrs.">Mrs.</option>
<option value="Miss.">Miss.</option>
<option value="Ms.">Ms.</option>
</select></div>
</div>
<div id="field_3_8" class="gfield gfield--type-text gfield--width-three-quarter input-style gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible"
data-js-reload="field_3_8"><label class="gfield_label gform-field-label" for="input_3_8">Surname:<span class="gfield_required"><span class="gfield_required gfield_required_text">(Required)</span></span></label>
<div class="ginput_container ginput_container_text"><input name="input_8" id="input_3_8" type="text" value="" class="large" aria-required="true" aria-invalid="false"> </div>
</div>
<div id="field_3_9" class="gfield gfield--type-text gfield--width-half input-style field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible" data-js-reload="field_3_9"><label
class="gfield_label gform-field-label" for="input_3_9">Previous surname:</label>
<div class="ginput_container ginput_container_text"><input name="input_9" id="input_3_9" type="text" value="" class="large" aria-invalid="false"> </div>
</div>
<div id="field_3_10" class="gfield gfield--type-text gfield--width-half input-style gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible"
data-js-reload="field_3_10"><label class="gfield_label gform-field-label" for="input_3_10">First Name(s):<span class="gfield_required"><span class="gfield_required gfield_required_text">(Required)</span></span></label>
<div class="ginput_container ginput_container_text"><input name="input_10" id="input_3_10" type="text" value="" class="large" aria-required="true" aria-invalid="false"> </div>
</div>
<div id="field_3_73" class="gfield gfield--type-text gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible" data-js-reload="field_3_73">
<label class="gfield_label gform-field-label" for="input_3_73">Birth country:<span class="gfield_required"><span class="gfield_required gfield_required_text">(Required)</span></span></label>
<div class="ginput_container ginput_container_text"><input name="input_73" id="input_3_73" type="text" value="" class="large" aria-required="true" aria-invalid="false"> </div>
</div>
<div id="field_3_20" class="gfield gfield--type-text gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible" data-js-reload="field_3_20">
<label class="gfield_label gform-field-label" for="input_3_20">Birth town:<span class="gfield_required"><span class="gfield_required gfield_required_text">(Required)</span></span></label>
<div class="ginput_container ginput_container_text"><input name="input_20" id="input_3_20" type="text" value="" class="large" aria-required="true" aria-invalid="false"> </div>
</div>
<div id="field_3_13" class="gfield gfield--type-textarea gfield--width-full input-style gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible"
data-js-reload="field_3_13"><label class="gfield_label gform-field-label" for="input_3_13">Home address:<span class="gfield_required"><span class="gfield_required gfield_required_text">(Required)</span></span></label>
<div class="ginput_container ginput_container_textarea"><textarea name="input_13" id="input_3_13" class="textarea small" aria-required="true" aria-invalid="false" rows="10" cols="50"></textarea></div>
</div>
<div id="field_3_15" class="gfield gfield--type-text gfield--width-third input-style gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible"
data-js-reload="field_3_15"><label class="gfield_label gform-field-label" for="input_3_15">Postcode:<span class="gfield_required"><span class="gfield_required gfield_required_text">(Required)</span></span></label>
<div class="ginput_container ginput_container_text"><input name="input_15" id="input_3_15" type="text" value="" class="large" aria-required="true" aria-invalid="false"> </div>
</div>
<div id="field_3_14" class="gfield gfield--type-text gfield--width-two-thirds input-style gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible"
data-js-reload="field_3_14"><label class="gfield_label gform-field-label" for="input_3_14">Telephone:<span class="gfield_required"><span class="gfield_required gfield_required_text">(Required)</span></span></label>
<div class="ginput_container ginput_container_text"><input name="input_14" id="input_3_14" type="text" value="" class="large" aria-required="true" aria-invalid="false"> </div>
</div>
<div id="field_3_16"
class="gfield gfield--type-date gfield--input-type-datepicker gfield--datepicker-default-icon gfield--width-third input-style gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible"
data-js-reload="field_3_16"><label class="gfield_label gform-field-label" for="input_3_16">Date of birth:<span class="gfield_required"><span class="gfield_required gfield_required_text">(Required)</span></span></label>
<div class="ginput_container ginput_container_date">
<input name="input_16" id="input_3_16" type="text" value="" class="datepicker gform-datepicker dmy datepicker_with_icon gdatepicker_with_icon hasDatepicker initialized" placeholder="dd/mm/yyyy" aria-describedby="input_3_16_date_format"
aria-invalid="false" aria-required="true"><img class="ui-datepicker-trigger" src="https://nhsgp.net/wp-content/plugins/gravityforms/images/datepicker/datepicker.svg" alt="Select date" title="Select date">
<span id="input_3_16_date_format" class="screen-reader-text">DD slash MM slash YYYY</span>
</div>
<input type="hidden" id="gforms_calendar_icon_input_3_16" class="gform_hidden" value="https://nhsgp.net/wp-content/plugins/gravityforms/images/datepicker/datepicker.svg">
</div>
<div id="field_3_17" class="gfield gfield--type-text gfield--width-third field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible" data-js-reload="field_3_17"><label
class="gfield_label gform-field-label" for="input_3_17">NHS Number:</label>
<div class="ginput_container ginput_container_text"><input name="input_17" id="input_3_17" type="text" value="" class="large" aria-invalid="false"> </div>
</div>
<fieldset id="field_3_22" class="gfield gfield--type-radio gfield--type-choice gfield--width-third field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible"
data-js-reload="field_3_22">
<legend class="gfield_label gform-field-label">Sex:</legend>
<div class="ginput_container ginput_container_radio">
<div class="gfield_radio" id="input_3_22">
<div class="gchoice gchoice_3_22_0">
<input class="gfield-choice-input" name="input_22" type="radio" value="Male" id="choice_3_22_0" onchange="gformToggleRadioOther( this )">
<label for="choice_3_22_0" id="label_3_22_0" class="gform-field-label gform-field-label--type-inline">Male</label>
</div>
<div class="gchoice gchoice_3_22_1">
<input class="gfield-choice-input" name="input_22" type="radio" value="Female" id="choice_3_22_1" onchange="gformToggleRadioOther( this )">
<label for="choice_3_22_1" id="label_3_22_1" class="gform-field-label gform-field-label--type-inline">Female</label>
</div>
</div>
</div>
</fieldset>
<div id="field_3_23" class="gfield gfield--type-text gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible" data-js-reload="field_3_23"><label
class="gfield_label gform-field-label" for="input_3_23">I am a student at:</label>
<div class="ginput_container ginput_container_text"><input name="input_23" id="input_3_23" type="text" value="" class="large" aria-invalid="false"> </div>
</div>
<div id="field_3_24" class="gfield gfield--type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible"
data-js-reload="field_3_24">
<div class="frm-info">
<h5>Patient's Details</h5>
</div>
</div>
<div id="field_3_26" class="gfield gfield--type-textarea gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible" data-js-reload="field_3_26"><label
class="gfield_label gform-field-label" for="input_3_26">Your previous address:</label>
<div class="ginput_container ginput_container_textarea"><textarea name="input_26" id="input_3_26" class="textarea small" aria-invalid="false" rows="10" cols="50"></textarea></div>
</div>
<div id="field_3_27" class="gfield gfield--type-textarea gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible" data-js-reload="field_3_27"><label
class="gfield_label gform-field-label" for="input_3_27">Name and address of previous GP while at previous address:</label>
<div class="ginput_container ginput_container_textarea"><textarea name="input_27" id="input_3_27" class="textarea small" aria-invalid="false" rows="10" cols="50"></textarea></div>
</div>
<div id="field_3_28"
class="gfield gfield--type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible"
data-js-reload="field_3_28">
<div class="frm-info">
<h5>If you are from abroad</h5>
</div>
</div>
<div id="field_3_29" class="gfield gfield--type-textarea gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible" data-js-reload="field_3_29"><label
class="gfield_label gform-field-label" for="input_3_29">Your first UK address where registered with a GP:</label>
<div class="ginput_container ginput_container_textarea"><textarea name="input_29" id="input_3_29" class="textarea small" aria-invalid="false" rows="10" cols="50"></textarea></div>
</div>
<div id="field_3_31"
class="gfield gfield--type-date gfield--input-type-datepicker gfield--datepicker-default-icon gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible"
data-js-reload="field_3_31"><label class="gfield_label gform-field-label" for="input_3_31">If previously resident in UK, date of leaving</label>
<div class="ginput_container ginput_container_date">
<input name="input_31" id="input_3_31" type="text" value="" class="datepicker gform-datepicker mdy datepicker_with_icon gdatepicker_with_icon hasDatepicker initialized" placeholder="mm/dd/yyyy" aria-describedby="input_3_31_date_format"
aria-invalid="false"><img class="ui-datepicker-trigger" src="https://nhsgp.net/wp-content/plugins/gravityforms/images/datepicker/datepicker.svg" alt="Select date" title="Select date">
<span id="input_3_31_date_format" class="screen-reader-text">MM slash DD slash YYYY</span>
</div>
<input type="hidden" id="gforms_calendar_icon_input_3_31" class="gform_hidden" value="https://nhsgp.net/wp-content/plugins/gravityforms/images/datepicker/datepicker.svg">
</div>
<div id="field_3_32"
class="gfield gfield--type-date gfield--input-type-datepicker gfield--datepicker-default-icon gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible"
data-js-reload="field_3_32"><label class="gfield_label gform-field-label" for="input_3_32">Date you first came to live in UK</label>
<div class="ginput_container ginput_container_date">
<input name="input_32" id="input_3_32" type="text" value="" class="datepicker gform-datepicker mdy datepicker_with_icon gdatepicker_with_icon hasDatepicker initialized" placeholder="mm/dd/yyyy" aria-describedby="input_3_32_date_format"
aria-invalid="false"><img class="ui-datepicker-trigger" src="https://nhsgp.net/wp-content/plugins/gravityforms/images/datepicker/datepicker.svg" alt="Select date" title="Select date">
<span id="input_3_32_date_format" class="screen-reader-text">MM slash DD slash YYYY</span>
</div>
<input type="hidden" id="gforms_calendar_icon_input_3_32" class="gform_hidden" value="https://nhsgp.net/wp-content/plugins/gravityforms/images/datepicker/datepicker.svg">
</div>
<div id="field_3_30"
class="gfield gfield--type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible"
data-js-reload="field_3_30">
<div class="frm-info">
<h5>If you are returning from the armed forces</h5>
</div>
</div>
<div id="field_3_42" class="gfield gfield--type-textarea gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible" data-js-reload="field_3_42"><label
class="gfield_label gform-field-label" for="input_3_42">Address before enlisting:</label>
<div class="ginput_container ginput_container_textarea"><textarea name="input_42" id="input_3_42" class="textarea small" aria-invalid="false" rows="10" cols="50"></textarea></div>
</div>
<div id="field_3_43" class="gfield gfield--type-text gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible" data-js-reload="field_3_43"><label
class="gfield_label gform-field-label" for="input_3_43">Service/Personnel No.</label>
<div class="ginput_container ginput_container_text"><input name="input_43" id="input_3_43" type="text" value="" class="large" aria-invalid="false"> </div>
</div>
<div id="field_3_44"
class="gfield gfield--type-date gfield--input-type-datepicker gfield--datepicker-default-icon gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible"
data-js-reload="field_3_44"><label class="gfield_label gform-field-label" for="input_3_44">Enlistment date:</label>
<div class="ginput_container ginput_container_date">
<input name="input_44" id="input_3_44" type="text" value="" class="datepicker gform-datepicker dmy datepicker_with_icon gdatepicker_with_icon hasDatepicker initialized" placeholder="dd/mm/yyyy" aria-describedby="input_3_44_date_format"
aria-invalid="false"><img class="ui-datepicker-trigger" src="https://nhsgp.net/wp-content/plugins/gravityforms/images/datepicker/datepicker.svg" alt="Select date" title="Select date">
<span id="input_3_44_date_format" class="screen-reader-text">DD slash MM slash YYYY</span>
</div>
<input type="hidden" id="gforms_calendar_icon_input_3_44" class="gform_hidden" value="https://nhsgp.net/wp-content/plugins/gravityforms/images/datepicker/datepicker.svg">
</div>
<fieldset id="field_3_45" class="gfield gfield--type-checkbox gfield--type-choice gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible"
data-js-reload="field_3_45">
<legend class="gfield_label gform-field-label gfield_label_before_complex">If you are registering a child under 5</legend>
<div class="ginput_container ginput_container_checkbox">
<div class="gfield_checkbox" id="input_3_45">
<div class="gchoice gchoice_3_45_1">
<input class="gfield-choice-input" name="input_45.1" type="checkbox" value="I wish the child above to be registered with the named doctor for Child Health Surveillance" id="choice_3_45_1">
<label for="choice_3_45_1" id="label_3_45_1" class="gform-field-label gform-field-label--type-inline">I wish the child above to be registered with the named doctor for Child Health Surveillance</label>
</div>
</div>
</div>
</fieldset>
<fieldset id="field_3_46" class="gfield gfield--type-checkbox gfield--type-choice gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible"
data-js-reload="field_3_46">
<legend class="gfield_label gform-field-label gfield_label_before_complex">If you need your doctor to dispense medicines and appliances</legend>
<div class="ginput_container ginput_container_checkbox">
<div class="gfield_checkbox" id="input_3_46">
<div class="gchoice gchoice_3_46_1">
<input class="gfield-choice-input" name="input_46.1" type="checkbox" value="I live more than 1 mile in a straight line from the nearest chemist" id="choice_3_46_1">
<label for="choice_3_46_1" id="label_3_46_1" class="gform-field-label gform-field-label--type-inline">I live more than 1 mile in a straight line from the nearest chemist</label>
</div>
<div class="gchoice gchoice_3_46_2">
<input class="gfield-choice-input" name="input_46.2" type="checkbox" value="I would have serious difficulty in getting them from a chemist" id="choice_3_46_2">
<label for="choice_3_46_2" id="label_3_46_2" class="gform-field-label gform-field-label--type-inline">I would have serious difficulty in getting them from a chemist</label>
</div>
<div class="gchoice gchoice_3_46_3">
<input class="gfield-choice-input" name="input_46.3" type="checkbox" value="Signature of patient" id="choice_3_46_3">
<label for="choice_3_46_3" id="label_3_46_3" class="gform-field-label gform-field-label--type-inline">Signature of patient</label>
</div>
<div class="gchoice gchoice_3_46_4">
<input class="gfield-choice-input" name="input_46.4" type="checkbox" value="Signature on behalf of patient" id="choice_3_46_4">
<label for="choice_3_46_4" id="label_3_46_4" class="gform-field-label gform-field-label--type-inline">Signature on behalf of patient</label>
</div>
</div>
</div>
</fieldset>
<div id="field_3_47"
class="gfield gfield--type-date gfield--input-type-datepicker gfield--datepicker-default-icon gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible"
data-js-reload="field_3_47"><label class="gfield_label gform-field-label" for="input_3_47">Date:</label>
<div class="ginput_container ginput_container_date">
<input name="input_47" id="input_3_47" type="text" value="" class="datepicker gform-datepicker dmy datepicker_with_icon gdatepicker_with_icon hasDatepicker initialized" placeholder="dd/mm/yyyy" aria-describedby="input_3_47_date_format"
aria-invalid="false"><img class="ui-datepicker-trigger" src="https://nhsgp.net/wp-content/plugins/gravityforms/images/datepicker/datepicker.svg" alt="Select date" title="Select date">
<span id="input_3_47_date_format" class="screen-reader-text">DD slash MM slash YYYY</span>
</div>
<input type="hidden" id="gforms_calendar_icon_input_3_47" class="gform_hidden" value="https://nhsgp.net/wp-content/plugins/gravityforms/images/datepicker/datepicker.svg">
</div>
<div id="field_3_35"
class="gfield gfield--type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible"
data-js-reload="field_3_35">
<div class="frm-info">
<h5>NHS Organ Donor Registration</h5>
</div>
</div>
<fieldset id="field_3_48" class="gfield gfield--type-checkbox gfield--type-choice gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible"
data-js-reload="field_3_48">
<legend class="gfield_label gform-field-label gfield_label_before_complex">I want to register my details on the NHS Organ Donor Register as someone whose organs/tissue may be used for transplantation after my death. Please tick the boxes that
apply:</legend>
<div class="ginput_container ginput_container_checkbox">
<div class="gfield_checkbox" id="input_3_48">
<div class="gchoice gchoice_3_48_1">
<input class="gfield-choice-input" name="input_48.1" type="checkbox" value="Any of my organs or" id="choice_3_48_1">
<label for="choice_3_48_1" id="label_3_48_1" class="gform-field-label gform-field-label--type-inline">Any of my organs or</label>
</div>
<div class="gchoice gchoice_3_48_2">
<input class="gfield-choice-input" name="input_48.2" type="checkbox" value="Kidneys" id="choice_3_48_2">
<label for="choice_3_48_2" id="label_3_48_2" class="gform-field-label gform-field-label--type-inline">Kidneys</label>
</div>
<div class="gchoice gchoice_3_48_3">
<input class="gfield-choice-input" name="input_48.3" type="checkbox" value="Heart" id="choice_3_48_3">
<label for="choice_3_48_3" id="label_3_48_3" class="gform-field-label gform-field-label--type-inline">Heart</label>
</div>
<div class="gchoice gchoice_3_48_4">
<input class="gfield-choice-input" name="input_48.4" type="checkbox" value="Liver" id="choice_3_48_4">
<label for="choice_3_48_4" id="label_3_48_4" class="gform-field-label gform-field-label--type-inline">Liver</label>
</div>
<div class="gchoice gchoice_3_48_5">
<input class="gfield-choice-input" name="input_48.5" type="checkbox" value="Corneas" id="choice_3_48_5">
<label for="choice_3_48_5" id="label_3_48_5" class="gform-field-label gform-field-label--type-inline">Corneas</label>
</div>
<div class="gchoice gchoice_3_48_6">
<input class="gfield-choice-input" name="input_48.6" type="checkbox" value="Lungs" id="choice_3_48_6">
<label for="choice_3_48_6" id="label_3_48_6" class="gform-field-label gform-field-label--type-inline">Lungs</label>
</div>
<div class="gchoice gchoice_3_48_7">
<input class="gfield-choice-input" name="input_48.7" type="checkbox" value="Pancreas" id="choice_3_48_7">
<label for="choice_3_48_7" id="label_3_48_7" class="gform-field-label gform-field-label--type-inline">Pancreas</label>
</div>
<div class="gchoice gchoice_3_48_8">
<input class="gfield-choice-input" name="input_48.8" type="checkbox" value="Any part of my body" id="choice_3_48_8">
<label for="choice_3_48_8" id="label_3_48_8" class="gform-field-label gform-field-label--type-inline">Any part of my body</label>
</div>
</div>
</div>
</fieldset>
<div id="field_3_36"
class="gfield gfield--type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible"
data-js-reload="field_3_36">
<div class="frm-info">
<h5>NHS Blood Donor Registration</h5>
<p>I would like to join the NHS Blood Donor Register as someone who may be contacted and would be prepared to donate blood.</p>
</div>
</div>
<fieldset id="field_3_50" class="gfield gfield--type-checkbox gfield--type-choice gfield--width-full field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible"
data-js-reload="field_3_50">
<legend class="gfield_label gform-field-label gfield_label_before_complex">Tick here if you have given blood in the last 3 years</legend>
<div class="ginput_container ginput_container_checkbox">
<div class="gfield_checkbox" id="input_3_50">
<div class="gchoice gchoice_3_50_1">
<input class="gfield-choice-input" name="input_50.1" type="checkbox" value="Tick here if you have given blood in the last 3 years" id="choice_3_50_1">
<label for="choice_3_50_1" id="label_3_50_1" class="gform-field-label gform-field-label--type-inline">Tick here if you have given blood in the last 3 years</label>
</div>
</div>
</div>
</fieldset>
<div id="field_3_51" class="gfield gfield--type-textarea gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible" data-js-reload="field_3_51"><label
class="gfield_label gform-field-label" for="input_3_51">For more information, please ask for the leaflet on joining the NHS Blood Donor Register Preferred address for donation: (if different from above, e.g. place of work)</label>
<div class="ginput_container ginput_container_textarea"><textarea name="input_51" id="input_3_51" class="textarea small" aria-invalid="false" rows="10" cols="50"></textarea></div>
</div>
<div id="field_3_52" class="gfield gfield--type-text gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible" data-js-reload="field_3_52"><label
class="gfield_label gform-field-label" for="input_3_52">Postcode:</label>
<div class="ginput_container ginput_container_text"><input name="input_52" id="input_3_52" type="text" value="" class="large" aria-invalid="false"> </div>
</div>
<div id="field_3_37"
class="gfield gfield--type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible"
data-js-reload="field_3_37">
<div class="frm-info">
<h5>Supplementary questions</h5>
</div>
</div>
<div id="field_3_38"
class="gfield gfield--type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible"
data-js-reload="field_3_38">
<div class="frm-info">
<h5>PATIENT DECLARATION for all patients who are not ordinarily resident in the UK</h5>
</div> Anybody in England can register with a GP practice and receive free medical care from that practice. However, if you are not 'ordinarily resident' in the UK you may have to pay for NHS treatment outside of the GP practice. Being
ordinarily resident broadly means living lawfully in the UK on a properly settled basis for the time being. In most cases, nationals of countries outside the European Economic Area must also have the status of 'indefinite leave to remain' in
the UK. Some services, such as diagnostic tests of suspected infectious diseases and any treatment of those diseases are free of charge to all people, while some groups who are not ordinarily resident here are exempt from all treatment
charges. More information on ordinary residence, exemptions and paying for NHS services can be found in the Visitor and Migrant patient leaflet, available from your GP practice. You may be asked to provide proof of entitlement in order to
receive free NHS treatment outside of the GP practice, otherwise you may be charged for your treatment. Even if you have to pay for a service, you will always be provided with any immediately necessary or urgent treatment, regardless of
advance payment. The information you give on this form will be used to assist in identifying your chargeable status, and may be shared, including with NHS secondary care organisations (e.g. hospitals) and NHS Digital, for the purposes of
validation, invoicing and cost recovery. You may be contacted on behalf of the NHS to confirm any details you have provided.
</div>
<div id="field_3_39"
class="gfield gfield--type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible"
data-js-reload="field_3_39">
<div class="frm-info">
<h5>Complete this section if you live in another EEA country, or have moved to the UK to study or retire, or if you live in the UK but work in another EEA member state. Do not complete this section if you have an EHIC issued by the UK.</h5>
</div>
</div>
<fieldset id="field_3_54" class="gfield gfield--type-radio gfield--type-choice gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible" data-js-reload="field_3_54">
<legend class="gfield_label gform-field-label">Please tick one of the following boxes:</legend>
<div class="ginput_container ginput_container_radio">
<div class="gfield_radio" id="input_3_54">
<div class="gchoice gchoice_3_54_0">
<input class="gfield-choice-input" name="input_54" type="radio" value="I understand that I may need to pay for NHS treatment outside of the GP practice" id="choice_3_54_0" onchange="gformToggleRadioOther( this )">
<label for="choice_3_54_0" id="label_3_54_0" class="gform-field-label gform-field-label--type-inline">I understand that I may need to pay for NHS treatment outside of the GP practice</label>
</div>
<div class="gchoice gchoice_3_54_1">
<input class="gfield-choice-input" name="input_54" type="radio"
value="I understand I have a valid exemption from paying for NHS treatment outside of the GP practice. This includes for example, an EHIC, or payment of the Immigration Health Charge ('the Surcharge'), when accompanied by a valid visa. I can provide documents to support this when requested"
id="choice_3_54_1" onchange="gformToggleRadioOther( this )">
<label for="choice_3_54_1" id="label_3_54_1" class="gform-field-label gform-field-label--type-inline">I understand I have a valid exemption from paying for NHS treatment outside of the GP practice. This includes for example, an EHIC, or
payment of the Immigration Health Charge ('the Surcharge'), when accompanied by a valid visa. I can provide documents to support this when requested</label>
</div>
<div class="gchoice gchoice_3_54_2">
<input class="gfield-choice-input" name="input_54" type="radio" value="I do not know my chargeable status" id="choice_3_54_2" onchange="gformToggleRadioOther( this )">
<label for="choice_3_54_2" id="label_3_54_2" class="gform-field-label gform-field-label--type-inline">I do not know my chargeable status</label>
</div>
</div>
</div>
</fieldset>
<fieldset id="field_3_53" class="gfield gfield--type-checkbox gfield--type-choice gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible"
data-js-reload="field_3_53">
<legend class="gfield_label gform-field-label gfield_label_before_complex">I declare that the information I give on this form is correct and complete. I understand that if it is not correct, appropriate action may be taken against me.<span
class="gfield_required"><span class="gfield_required gfield_required_text">(Required)</span></span></legend>
<div class="ginput_container ginput_container_checkbox">
<div class="gfield_checkbox" id="input_3_53">
<div class="gchoice gchoice_3_53_1">
<input class="gfield-choice-input" name="input_53.1" type="checkbox" value="Are you a parent or guardian, filling out this form on behalf of a child under 16?" id="choice_3_53_1">
<label for="choice_3_53_1" id="label_3_53_1" class="gform-field-label gform-field-label--type-inline">Are you a parent or guardian, filling out this form on behalf of a child under 16?</label>
</div>
</div>
</div>
</fieldset>
<div id="field_3_55" class="gfield gfield--type-text gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible" data-js-reload="field_3_55"><label
class="gfield_label gform-field-label" for="input_3_55">Name parent or guardian:</label>
<div class="ginput_container ginput_container_text"><input name="input_55" id="input_3_55" type="text" value="" class="large" aria-invalid="false"> </div>
</div>
<div id="field_3_56" class="gfield gfield--type-text gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible" data-js-reload="field_3_56"><label
class="gfield_label gform-field-label" for="input_3_56">Relationship to patient:</label>
<div class="ginput_container ginput_container_text"><input name="input_56" id="input_3_56" type="text" value="" class="large" aria-invalid="false"> </div>
</div>
<div id="field_3_40"
class="gfield gfield--type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible"
data-js-reload="field_3_40">
<div class="frm-info">
<h5>NON-UK EUROPEAN HEALTH INSURANCE CARD (EHIC), PROVISIONAL REPLACEMENT CERTIFICATE (PRC) DETAILS and S1 FORMS</h5>
</div>
</div>
<div id="field_3_41"
class="gfield gfield--type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible"
data-js-reload="field_3_41">
<div class="frm-info">
<h5>If you are visiting from another EEA country and do not hold a current EHIC (or Provisional Replacement Certificate (PRC)/S1, you may be billed for the cost of any treatment received outside the GP practice, including at hospital).</h5>
</div>
</div>
<fieldset id="field_3_57" class="gfield gfield--type-radio gfield--type-choice gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible" data-js-reload="field_3_57">
<legend class="gfield_label gform-field-label">Do you have a non-UK EHIC or PRC?</legend>
<div class="ginput_container ginput_container_radio">
<div class="gfield_radio" id="input_3_57">
<div class="gchoice gchoice_3_57_0">
<input class="gfield-choice-input" name="input_57" type="radio" value="Yes" id="choice_3_57_0" onchange="gformToggleRadioOther( this )">
<label for="choice_3_57_0" id="label_3_57_0" class="gform-field-label gform-field-label--type-inline">Yes</label>
</div>
<div class="gchoice gchoice_3_57_1">
<input class="gfield-choice-input" name="input_57" type="radio" value="No" id="choice_3_57_1" onchange="gformToggleRadioOther( this )">
<label for="choice_3_57_1" id="label_3_57_1" class="gform-field-label gform-field-label--type-inline">No</label>
</div>
</div>
</div>
</fieldset>
<div id="field_3_58"
class="gfield gfield--type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible"
data-js-reload="field_3_58">If yes, please enter details from your EHIC or PRC below:</div>
<div id="field_3_59" class="gfield gfield--type-text gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible" data-js-reload="field_3_59"><label
class="gfield_label gform-field-label" for="input_3_59">Name:</label>
<div class="ginput_container ginput_container_text"><input name="input_59" id="input_3_59" type="text" value="" class="large" aria-invalid="false"> </div>
</div>
<div id="field_3_60" class="gfield gfield--type-text gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible" data-js-reload="field_3_60"><label
class="gfield_label gform-field-label" for="input_3_60">Given names:</label>
<div class="ginput_container ginput_container_text"><input name="input_60" id="input_3_60" type="text" value="" class="large" aria-invalid="false"> </div>
</div>
<div id="field_3_61"
class="gfield gfield--type-date gfield--input-type-datepicker gfield--datepicker-default-icon gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible"
data-js-reload="field_3_61"><label class="gfield_label gform-field-label" for="input_3_61">Date of birth:</label>
<div class="ginput_container ginput_container_date">
<input name="input_61" id="input_3_61" type="text" value="" class="datepicker gform-datepicker dmy datepicker_with_icon gdatepicker_with_icon hasDatepicker initialized" placeholder="dd/mm/yyyy" aria-describedby="input_3_61_date_format"
aria-invalid="false"><img class="ui-datepicker-trigger" src="https://nhsgp.net/wp-content/plugins/gravityforms/images/datepicker/datepicker.svg" alt="Select date" title="Select date">
<span id="input_3_61_date_format" class="screen-reader-text">DD slash MM slash YYYY</span>
</div>
<input type="hidden" id="gforms_calendar_icon_input_3_61" class="gform_hidden" value="https://nhsgp.net/wp-content/plugins/gravityforms/images/datepicker/datepicker.svg">
</div>
<div id="field_3_62" class="gfield gfield--type-text gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible" data-js-reload="field_3_62"><label
class="gfield_label gform-field-label" for="input_3_62">Personal Identification Number:</label>
<div class="ginput_container ginput_container_text"><input name="input_62" id="input_3_62" type="text" value="" class="large" aria-invalid="false"> </div>
</div>
<div id="field_3_63" class="gfield gfield--type-text gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible" data-js-reload="field_3_63"><label
class="gfield_label gform-field-label" for="input_3_63">Country code:</label>
<div class="ginput_container ginput_container_text"><input name="input_63" id="input_3_63" type="text" value="" class="large" aria-invalid="false"> </div>
</div>
<div id="field_3_64"
class="gfield gfield--type-date gfield--input-type-datepicker gfield--datepicker-default-icon gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible"
data-js-reload="field_3_64"><label class="gfield_label gform-field-label" for="input_3_64">Expiry date:</label>
<div class="ginput_container ginput_container_date">
<input name="input_64" id="input_3_64" type="text" value="" class="datepicker gform-datepicker dmy datepicker_with_icon gdatepicker_with_icon hasDatepicker initialized" placeholder="dd/mm/yyyy" aria-describedby="input_3_64_date_format"
aria-invalid="false"><img class="ui-datepicker-trigger" src="https://nhsgp.net/wp-content/plugins/gravityforms/images/datepicker/datepicker.svg" alt="Select date" title="Select date">
<span id="input_3_64_date_format" class="screen-reader-text">DD slash MM slash YYYY</span>
</div>
<input type="hidden" id="gforms_calendar_icon_input_3_64" class="gform_hidden" value="https://nhsgp.net/wp-content/plugins/gravityforms/images/datepicker/datepicker.svg">
</div>
<div id="field_3_65" class="gfield gfield--type-text gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible" data-js-reload="field_3_65"><label
class="gfield_label gform-field-label" for="input_3_65">Identification number of the institution:</label>
<div class="ginput_container ginput_container_text"><input name="input_65" id="input_3_65" type="text" value="" class="large" aria-invalid="false"> </div>
</div>
<div id="field_3_66" class="gfield gfield--type-text gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible" data-js-reload="field_3_66"><label
class="gfield_label gform-field-label" for="input_3_66">Identification number of the card:</label>
<div class="ginput_container ginput_container_text"><input name="input_66" id="input_3_66" type="text" value="" class="large" aria-invalid="false"> </div>
</div>
<div id="field_3_67"
class="gfield gfield--type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible"
data-js-reload="field_3_67">PRC validity period</div>
<div id="field_3_68"
class="gfield gfield--type-date gfield--input-type-datepicker gfield--datepicker-default-icon gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible"
data-js-reload="field_3_68"><label class="gfield_label gform-field-label" for="input_3_68">From:</label>
<div class="ginput_container ginput_container_date">
<input name="input_68" id="input_3_68" type="text" value="" class="datepicker gform-datepicker dmy datepicker_with_icon gdatepicker_with_icon hasDatepicker initialized" placeholder="dd/mm/yyyy" aria-describedby="input_3_68_date_format"
aria-invalid="false"><img class="ui-datepicker-trigger" src="https://nhsgp.net/wp-content/plugins/gravityforms/images/datepicker/datepicker.svg" alt="Select date" title="Select date">
<span id="input_3_68_date_format" class="screen-reader-text">DD slash MM slash YYYY</span>
</div>
<input type="hidden" id="gforms_calendar_icon_input_3_68" class="gform_hidden" value="https://nhsgp.net/wp-content/plugins/gravityforms/images/datepicker/datepicker.svg">
</div>
<div id="field_3_69"
class="gfield gfield--type-date gfield--input-type-datepicker gfield--datepicker-default-icon gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible"
data-js-reload="field_3_69"><label class="gfield_label gform-field-label" for="input_3_69">To:</label>
<div class="ginput_container ginput_container_date">
<input name="input_69" id="input_3_69" type="text" value="" class="datepicker gform-datepicker dmy datepicker_with_icon gdatepicker_with_icon hasDatepicker initialized" placeholder="dd/mm/yyyy" aria-describedby="input_3_69_date_format"
aria-invalid="false"><img class="ui-datepicker-trigger" src="https://nhsgp.net/wp-content/plugins/gravityforms/images/datepicker/datepicker.svg" alt="Select date" title="Select date">
<span id="input_3_69_date_format" class="screen-reader-text">DD slash MM slash YYYY</span>
</div>
<input type="hidden" id="gforms_calendar_icon_input_3_69" class="gform_hidden" value="https://nhsgp.net/wp-content/plugins/gravityforms/images/datepicker/datepicker.svg">
</div>
<fieldset id="field_3_70"
class="gfield gfield--type-checkbox gfield--type-choice gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible"
data-js-reload="field_3_70">
<legend class="gfield_label gform-field-label gfield_label_before_complex">Untitled<span class="gfield_required"><span class="gfield_required gfield_required_text">(Required)</span></span></legend>
<div class="ginput_container ginput_container_checkbox">
<div class="gfield_checkbox" id="input_3_70">
<div class="gchoice gchoice_3_70_1">
<input class="gfield-choice-input" name="input_70.1" type="checkbox"
value="Please tick if you have an S1 (e.g. you are retiring to the UK or you have been posted here by your employer for work or you live in the UK but work in another EEA member state) Please give your S1 form to the practice staff."
id="choice_3_70_1">
<label for="choice_3_70_1" id="label_3_70_1" class="gform-field-label gform-field-label--type-inline">Please tick if you have an S1 (e.g. you are retiring to the UK or you have been posted here by your employer for work or you live in
the UK but work in another EEA member state) Please give your S1 form to the practice staff.</label>
</div>
</div>
</div>
</fieldset>
<div id="field_3_71"
class="gfield gfield--type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible"
data-js-reload="field_3_71">How will your EHIC/PRC/S1 data be used? By using your EHIC or PRC for NHS treatment costs your EHIC or PRC data and GP appointment data will be shared with NHS secondary care (hospitals) and NHS Digital solely for
the purposes of cost recovery. Your clinical data will not be shared in the cost recovery process. Your EHIC, PRC or S1 information will be shared with The Department for Work and Pensions for the purpose of recovering your NHS costs from
your home country.</div>
</div>
</div>
<div class="gform_footer top_label"> <input type="submit" id="gform_submit_button_3" class="gform_button button" value="Submit"
onclick="if(window["gf_submitting_3"]){return false;} if( !jQuery("#gform_3")[0].checkValidity || jQuery("#gform_3")[0].checkValidity()){window["gf_submitting_3"]=true;} "
onkeypress="if( event.keyCode == 13 ){ if(window["gf_submitting_3"]){return false;} if( !jQuery("#gform_3")[0].checkValidity || jQuery("#gform_3")[0].checkValidity()){window["gf_submitting_3"]=true;} jQuery("#gform_3").trigger("submit",[true]); }">
<input type="hidden" class="gform_hidden" name="is_submit_3" value="1">
<input type="hidden" class="gform_hidden" name="gform_submit" value="3">
<input type="hidden" class="gform_hidden" name="gform_unique_id" value="">
<input type="hidden" class="gform_hidden" name="state_3"
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<input type="hidden" name="gform_field_values" value="">
</div>
</form>POST /
<form method="post" enctype="multipart/form-data" id="gform_4" action="/" data-formid="4" novalidate="">
<div class="gform-body gform_body">
<div id="gform_fields_4" class="gform_fields top_label form_sublabel_below description_below validation_below">
<div id="field_4_1" class="gfield gfield--type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible"
data-js-reload="field_4_1">
<div class="frm-title">Are You A Carer?</div>
<div class="frm-desc">Do you look after a family member or friend who is unwell, disabled or frail?</div>
<div class="frm-desc">If so please complete this form. Once you are added to our list of carers we will know about your busy life as a carer, which can affect your health. We can also try and be flexible with appointments etc as we will know
about your commitments.</div>
<div class="fr-name">Carer details</div>
</div>
<div id="field_4_8" class="gfield gfield--type-select gfield--width-third field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible" data-js-reload="field_4_8"><label
class="gfield_label gform-field-label" for="input_4_8">Title:</label>
<div class="ginput_container ginput_container_select"><select name="input_8" id="input_4_8" class="large gfield_select" aria-invalid="false">
<option value="Mr.">Mr.</option>
<option value="Mrs.">Mrs.</option>
<option value="Miss.">Miss.</option>
<option value="Ms.">Ms.</option>
</select></div>
</div>
<div id="field_4_5" class="gfield gfield--type-text gfield--width-third gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible" data-js-reload="field_4_5">
<label class="gfield_label gform-field-label" for="input_4_5">First name:<span class="gfield_required"><span class="gfield_required gfield_required_text">(Required)</span></span></label>
<div class="ginput_container ginput_container_text"><input name="input_5" id="input_4_5" type="text" value="" class="large" aria-required="true" aria-invalid="false"> </div>
</div>
<div id="field_4_7" class="gfield gfield--type-text gfield--width-third gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible" data-js-reload="field_4_7">
<label class="gfield_label gform-field-label" for="input_4_7">Last name(s):<span class="gfield_required"><span class="gfield_required gfield_required_text">(Required)</span></span></label>
<div class="ginput_container ginput_container_text"><input name="input_7" id="input_4_7" type="text" value="" class="large" aria-required="true" aria-invalid="false"> </div>
</div>
<div id="field_4_14" class="gfield gfield--type-textarea gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible"
data-js-reload="field_4_14"><label class="gfield_label gform-field-label" for="input_4_14">Address:<span class="gfield_required"><span class="gfield_required gfield_required_text">(Required)</span></span></label>
<div class="ginput_container ginput_container_textarea"><textarea name="input_14" id="input_4_14" class="textarea small" aria-required="true" aria-invalid="false" rows="10" cols="50"></textarea></div>
</div>
<div id="field_4_23" class="gfield gfield--type-text gfield--width-third field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible" data-js-reload="field_4_23"><label
class="gfield_label gform-field-label" for="input_4_23">Postcode:</label>
<div class="ginput_container ginput_container_text"><input name="input_23" id="input_4_23" type="text" value="" class="large" aria-invalid="false"> </div>
</div>
<div id="field_4_9"
class="gfield gfield--type-date gfield--input-type-datepicker gfield--datepicker-default-icon gfield--width-third gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible"
data-js-reload="field_4_9"><label class="gfield_label gform-field-label" for="input_4_9">Date of birth:<span class="gfield_required"><span class="gfield_required gfield_required_text">(Required)</span></span></label>
<div class="ginput_container ginput_container_date">
<input name="input_9" id="input_4_9" type="text" value="" class="datepicker gform-datepicker dmy datepicker_with_icon gdatepicker_with_icon hasDatepicker initialized" placeholder="dd/mm/yyyy" aria-describedby="input_4_9_date_format"
aria-invalid="false" aria-required="true"><img class="ui-datepicker-trigger" src="https://nhsgp.net/wp-content/plugins/gravityforms/images/datepicker/datepicker.svg" alt="Select date" title="Select date">
<span id="input_4_9_date_format" class="screen-reader-text">DD slash MM slash YYYY</span>
</div>
<input type="hidden" id="gforms_calendar_icon_input_4_9" class="gform_hidden" value="https://nhsgp.net/wp-content/plugins/gravityforms/images/datepicker/datepicker.svg">
</div>
<div id="field_4_28" class="gfield gfield--type-phone gfield--width-third gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible"
data-js-reload="field_4_28"><label class="gfield_label gform-field-label" for="input_4_28">Telephone:<span class="gfield_required"><span class="gfield_required gfield_required_text">(Required)</span></span></label>
<div class="ginput_container ginput_container_phone"><input name="input_28" id="input_4_28" type="tel" value="" class="large" aria-required="true" aria-invalid="false"></div>
</div>
<div id="field_4_29" class="gfield gfield--type-email gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible" data-js-reload="field_4_29"><label
class="gfield_label gform-field-label" for="input_4_29">Email</label>
<div class="ginput_container ginput_container_email">
<input name="input_29" id="input_4_29" type="email" value="" class="large" aria-invalid="false">
</div>
</div>
<div id="field_4_15"
class="gfield gfield--type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible"
data-js-reload="field_4_15">
<div class="md-title">Details of Person Being Cared For</div>
</div>
<div id="field_4_25" class="gfield gfield--type-select gfield--width-third field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible" data-js-reload="field_4_25"><label
class="gfield_label gform-field-label" for="input_4_25">Title:</label>
<div class="ginput_container ginput_container_select"><select name="input_25" id="input_4_25" class="large gfield_select" aria-invalid="false">
<option value="Mr.">Mr.</option>
<option value="Mrs.">Mrs.</option>
<option value="Miss.">Miss.</option>
<option value="Ms.">Ms.</option>
</select></div>
</div>
<div id="field_4_26" class="gfield gfield--type-text gfield--width-third field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible" data-js-reload="field_4_26"><label
class="gfield_label gform-field-label" for="input_4_26">First name:</label>
<div class="ginput_container ginput_container_text"><input name="input_26" id="input_4_26" type="text" value="" class="large" aria-invalid="false"> </div>
</div>
<div id="field_4_27" class="gfield gfield--type-text gfield--width-third field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible" data-js-reload="field_4_27"><label
class="gfield_label gform-field-label" for="input_4_27">Last name(s):</label>
<div class="ginput_container ginput_container_text"><input name="input_27" id="input_4_27" type="text" value="" class="large" aria-invalid="false"> </div>
</div>
<div id="field_4_30" class="gfield gfield--type-textarea gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible" data-js-reload="field_4_30"><label
class="gfield_label gform-field-label" for="input_4_30">Address:</label>
<div class="ginput_container ginput_container_textarea"><textarea name="input_30" id="input_4_30" class="textarea small" aria-invalid="false" rows="10" cols="50"></textarea></div>
</div>
<div id="field_4_31" class="gfield gfield--type-text gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible" data-js-reload="field_4_31"><label
class="gfield_label gform-field-label" for="input_4_31">Postcode:</label>
<div class="ginput_container ginput_container_text"><input name="input_31" id="input_4_31" type="text" value="" class="large" aria-invalid="false"> </div>
</div>
<div id="field_4_32"
class="gfield gfield--type-date gfield--input-type-datepicker gfield--datepicker-no-icon gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible"
data-js-reload="field_4_32"><label class="gfield_label gform-field-label" for="input_4_32">Date of birth:</label>
<div class="ginput_container ginput_container_date">
<input name="input_32" id="input_4_32" type="text" value="" class="datepicker gform-datepicker dmy datepicker_no_icon gdatepicker-no-icon hasDatepicker initialized" placeholder="dd/mm/yyyy" aria-describedby="input_4_32_date_format"
aria-invalid="false">
<span id="input_4_32_date_format" class="screen-reader-text">DD slash MM slash YYYY</span>
</div>
<input type="hidden" id="gforms_calendar_icon_input_4_32" class="gform_hidden" value="https://nhsgp.net/wp-content/plugins/gravityforms/images/datepicker/datepicker.svg">
</div>
<div id="field_4_33" class="gfield gfield--type-text gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible" data-js-reload="field_4_33"><label
class="gfield_label gform-field-label" for="input_4_33">What relation is the person you care for?</label>
<div class="ginput_container ginput_container_text"><input name="input_33" id="input_4_33" type="text" value="" class="large" aria-invalid="false"> </div>
</div>
<fieldset id="field_4_34" class="gfield gfield--type-radio gfield--type-choice gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible" data-js-reload="field_4_34">
<legend class="gfield_label gform-field-label">Is the person you care for a patient at NHS GP?</legend>
<div class="ginput_container ginput_container_radio">
<div class="gfield_radio" id="input_4_34">
<div class="gchoice gchoice_4_34_0">
<input class="gfield-choice-input" name="input_34" type="radio" value="Yes" id="choice_4_34_0" onchange="gformToggleRadioOther( this )">
<label for="choice_4_34_0" id="label_4_34_0" class="gform-field-label gform-field-label--type-inline">Yes</label>
</div>
<div class="gchoice gchoice_4_34_1">
<input class="gfield-choice-input" name="input_34" type="radio" value="No" id="choice_4_34_1" onchange="gformToggleRadioOther( this )">
<label for="choice_4_34_1" id="label_4_34_1" class="gform-field-label gform-field-label--type-inline">No</label>
</div>
</div>
</div>
</fieldset>
</div>
</div>
<div class="gform_footer top_label"> <input type="submit" id="gform_submit_button_4" class="gform_button button" value="Submit"
onclick="if(window["gf_submitting_4"]){return false;} if( !jQuery("#gform_4")[0].checkValidity || jQuery("#gform_4")[0].checkValidity()){window["gf_submitting_4"]=true;} "
onkeypress="if( event.keyCode == 13 ){ if(window["gf_submitting_4"]){return false;} if( !jQuery("#gform_4")[0].checkValidity || jQuery("#gform_4")[0].checkValidity()){window["gf_submitting_4"]=true;} jQuery("#gform_4").trigger("submit",[true]); }">
<input type="hidden" class="gform_hidden" name="is_submit_4" value="1">
<input type="hidden" class="gform_hidden" name="gform_submit" value="4">
<input type="hidden" class="gform_hidden" name="gform_unique_id" value="">
<input type="hidden" class="gform_hidden" name="state_4" value="WyJ7XCIzNFwiOltcIjE5YTExMzQ4YThlZWI0MTY4MjBiYWZmNWFiZDEyZmVmXCIsXCI5NDhlZTE1MTcwNDE3MzNiOTE5MzU5NGU5MWQ3MzE3NlwiXX0iLCI5ODEzN2MwNWZhOGNjMmQ3ZTM5OTAyMzI1MzQ3MDlkZCJd">
<input type="hidden" class="gform_hidden" name="gform_target_page_number_4" id="gform_target_page_number_4" value="0">
<input type="hidden" class="gform_hidden" name="gform_source_page_number_4" id="gform_source_page_number_4" value="1">
<input type="hidden" name="gform_field_values" value="">
</div>
</form>POST /
<form method="post" enctype="multipart/form-data" id="gform_5" action="/" data-formid="5" novalidate="">
<div class="gform-body gform_body">
<div id="gform_fields_5" class="gform_fields top_label form_sublabel_below description_below validation_below">
<div id="field_5_1" class="gfield gfield--type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible"
data-js-reload="field_5_1">
<div class="frm-title">Asthma Annual Review Questionnaire</div>
</div>
<div id="field_5_3"
class="gfield gfield--type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible"
data-js-reload="field_5_3">
<div class="frm-info">
<h5>Contact details</h5>
</div>
</div>
<div id="field_5_4" class="gfield gfield--type-text gfield--width-two-thirds gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible"
data-js-reload="field_5_4"><label class="gfield_label gform-field-label" for="input_5_4">Name:<span class="gfield_required"><span class="gfield_required gfield_required_text">(Required)</span></span></label>
<div class="ginput_container ginput_container_text"><input name="input_4" id="input_5_4" type="text" value="" class="large" aria-required="true" aria-invalid="false"> </div>
</div>
<div id="field_5_5"
class="gfield gfield--type-date gfield--input-type-datepicker gfield--datepicker-default-icon gfield--width-third gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible"
data-js-reload="field_5_5"><label class="gfield_label gform-field-label" for="input_5_5">Date of birth:<span class="gfield_required"><span class="gfield_required gfield_required_text">(Required)</span></span></label>
<div class="ginput_container ginput_container_date">
<input name="input_5" id="input_5_5" type="text" value="" class="datepicker gform-datepicker dmy datepicker_with_icon gdatepicker_with_icon hasDatepicker initialized" placeholder="dd/mm/yyyy" aria-describedby="input_5_5_date_format"
aria-invalid="false" aria-required="true"><img class="ui-datepicker-trigger" src="https://nhsgp.net/wp-content/plugins/gravityforms/images/datepicker/datepicker.svg" alt="Select date" title="Select date">
<span id="input_5_5_date_format" class="screen-reader-text">DD slash MM slash YYYY</span>
</div>
<input type="hidden" id="gforms_calendar_icon_input_5_5" class="gform_hidden" value="https://nhsgp.net/wp-content/plugins/gravityforms/images/datepicker/datepicker.svg">
</div>
<div id="field_5_6" class="gfield gfield--type-phone gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible" data-js-reload="field_5_6">
<label class="gfield_label gform-field-label" for="input_5_6">Home phone:<span class="gfield_required"><span class="gfield_required gfield_required_text">(Required)</span></span></label>
<div class="ginput_container ginput_container_phone"><input name="input_6" id="input_5_6" type="tel" value="" class="large" aria-required="true" aria-invalid="false"></div>
</div>
<div id="field_5_7" class="gfield gfield--type-phone gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible" data-js-reload="field_5_7">
<label class="gfield_label gform-field-label" for="input_5_7">Mobile phone:<span class="gfield_required"><span class="gfield_required gfield_required_text">(Required)</span></span></label>
<div class="ginput_container ginput_container_phone"><input name="input_7" id="input_5_7" type="tel" value="" class="large" aria-required="true" aria-invalid="false"></div>
</div>
<div id="field_5_8" class="gfield gfield--type-email gfield--width-two-thirds gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible"
data-js-reload="field_5_8"><label class="gfield_label gform-field-label" for="input_5_8">Email:<span class="gfield_required"><span class="gfield_required gfield_required_text">(Required)</span></span></label>
<div class="ginput_container ginput_container_email">
<input name="input_8" id="input_5_8" type="email" value="" class="large" aria-required="true" aria-invalid="false">
</div>
</div>
<div id="field_5_9" class="gfield gfield--type-text gfield--width-third field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible" data-js-reload="field_5_9"><label
class="gfield_label gform-field-label" for="input_5_9">Postcode</label>
<div class="ginput_container ginput_container_text"><input name="input_9" id="input_5_9" type="text" value="" class="large" aria-invalid="false"> </div>
</div>
<div id="field_5_10" class="gfield gfield--type-textarea gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible"
data-js-reload="field_5_10"><label class="gfield_label gform-field-label" for="input_5_10">Home address:<span class="gfield_required"><span class="gfield_required gfield_required_text">(Required)</span></span></label>
<div class="ginput_container ginput_container_textarea"><textarea name="input_10" id="input_5_10" class="textarea small" aria-required="true" aria-invalid="false" rows="10" cols="50"></textarea></div>
</div>
<div id="field_5_11"
class="gfield gfield--type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible"
data-js-reload="field_5_11">Questionnaire</div>
<div id="field_5_12" class="gfield gfield--type-select gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible" data-js-reload="field_5_12"><label
class="gfield_label gform-field-label" for="input_5_12">1. When was your asthma diagnosed?</label>
<div class="ginput_container ginput_container_select"><select name="input_12" id="input_5_12" class="large gfield_select" aria-invalid="false">
<option value="Less than 5 years ago">Less than 5 years ago</option>
<option value="More than 5 years ago">More than 5 years ago</option>
<option value="Less than 10 years ago">Less than 10 years ago</option>
</select></div>
</div>
<div id="field_5_13" class="gfield gfield--type-select gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible" data-js-reload="field_5_13"><label
class="gfield_label gform-field-label" for="input_5_13">2. In the last month, have you had any difficulty sleeping because of your asthma symptoms (including cough)?</label>
<div class="ginput_container ginput_container_select"><select name="input_13" id="input_5_13" class="large gfield_select" aria-invalid="false">
<option value="No">No</option>
<option value="Yes, every day">Yes, every day</option>
<option value="Yes, 1-2 times a week">Yes, 1-2 times a week</option>
<option value="Yes, 1-2 times a month">Yes, 1-2 times a month</option>
<option value="Yes, 1-2 times a year">Yes, 1-2 times a year</option>
<option value="Yes, see below for details">Yes, see below for details</option>
</select></div>
</div>
<div id="field_5_14" class="gfield gfield--type-textarea gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible" data-js-reload="field_5_14"><label
class="gfield_label gform-field-label" for="input_5_14">Details of sleeping difficulties:</label>
<div class="ginput_container ginput_container_textarea"><textarea name="input_14" id="input_5_14" class="textarea small" aria-invalid="false" rows="10" cols="50"></textarea></div>
</div>
<div id="field_5_15" class="gfield gfield--type-select gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible" data-js-reload="field_5_15"><label
class="gfield_label gform-field-label" for="input_5_15">3. In the last month, have you had your usual asthma symptoms during the day? (cough, wheeze, chest tightness or breathlessness)?</label>
<div class="ginput_container ginput_container_select"><select name="input_15" id="input_5_15" class="large gfield_select" aria-invalid="false">
<option value="No">No</option>
<option value="Yes, every day">Yes, every day</option>
<option value="Yes, 1-2 times a week">Yes, 1-2 times a week</option>
<option value="Yes, 1-2 times a month">Yes, 1-2 times a month</option>
<option value="Yes, 1-2 times a year">Yes, 1-2 times a year</option>
<option value="Yes, see below for details">Yes, see below for details</option>
</select></div>
</div>
<div id="field_5_16" class="gfield gfield--type-textarea gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible" data-js-reload="field_5_16"><label
class="gfield_label gform-field-label" for="input_5_16">Details of symptoms during the day:</label>
<div class="ginput_container ginput_container_textarea"><textarea name="input_16" id="input_5_16" class="textarea small" aria-invalid="false" rows="10" cols="50"></textarea></div>
</div>
<div id="field_5_17" class="gfield gfield--type-select gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible" data-js-reload="field_5_17"><label
class="gfield_label gform-field-label" for="input_5_17">4. How often do you use your blue inhaler?</label>
<div class="ginput_container ginput_container_select"><select name="input_17" id="input_5_17" class="large gfield_select" aria-invalid="false">
<option value="Daily">Daily</option>
<option value="Weekly">Weekly</option>
<option value="Monthly">Monthly</option>
<option value="Yearly">Yearly</option>
<option value="Other, see below for details">Other, see below for details</option>
</select></div>
</div>
<div id="field_5_18" class="gfield gfield--type-textarea gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible" data-js-reload="field_5_18"><label
class="gfield_label gform-field-label" for="input_5_18">Details of inhaler use:</label>
<div class="ginput_container ginput_container_textarea"><textarea name="input_18" id="input_5_18" class="textarea small" aria-invalid="false" rows="10" cols="50"></textarea></div>
</div>
<fieldset id="field_5_19" class="gfield gfield--type-radio gfield--type-choice gfield--width-third field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible"
data-js-reload="field_5_19">
<legend class="gfield_label gform-field-label">5. In the last month has your asthma interfered with your usual activities (e.g. housework, work, school etc)?</legend>
<div class="ginput_container ginput_container_radio">
<div class="gfield_radio" id="input_5_19">
<div class="gchoice gchoice_5_19_0">
<input class="gfield-choice-input" name="input_19" type="radio" value="Yes" id="choice_5_19_0" onchange="gformToggleRadioOther( this )">
<label for="choice_5_19_0" id="label_5_19_0" class="gform-field-label gform-field-label--type-inline">Yes</label>
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<div class="gchoice gchoice_5_19_1">
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<label for="choice_5_19_1" id="label_5_19_1" class="gform-field-label gform-field-label--type-inline">No</label>
</div>
</div>
</div>
</fieldset>
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data-js-reload="field_5_20">
<legend class="gfield_label gform-field-label">6. Have you ever had your peak flow measured at the surgery?</legend>
<div class="ginput_container ginput_container_radio">
<div class="gfield_radio" id="input_5_20">
<div class="gchoice gchoice_5_20_0">
<input class="gfield-choice-input" name="input_20" type="radio" value="Yes" id="choice_5_20_0" onchange="gformToggleRadioOther( this )">
<label for="choice_5_20_0" id="label_5_20_0" class="gform-field-label gform-field-label--type-inline">Yes</label>
</div>
<div class="gchoice gchoice_5_20_1">
<input class="gfield-choice-input" name="input_20" type="radio" value="No" id="choice_5_20_1" onchange="gformToggleRadioOther( this )">
<label for="choice_5_20_1" id="label_5_20_1" class="gform-field-label gform-field-label--type-inline">No</label>
</div>
</div>
</div>
</fieldset>
<div id="field_5_21" class="gfield gfield--type-text gfield--width-third field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible" data-js-reload="field_5_21"><label
class="gfield_label gform-field-label" for="input_5_21">If yes, do you know your best PEFR value</label>
<div class="ginput_container ginput_container_text"><input name="input_21" id="input_5_21" type="text" value="" class="large" placeholder="ml/min" aria-invalid="false"> </div>
</div>
<fieldset id="field_5_22" class="gfield gfield--type-radio gfield--type-choice gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible" data-js-reload="field_5_22">
<legend class="gfield_label gform-field-label">7. Are you happy with your inhaler technique?</legend>
<div class="ginput_container ginput_container_radio">
<div class="gfield_radio" id="input_5_22">
<div class="gchoice gchoice_5_22_0">
<input class="gfield-choice-input" name="input_22" type="radio" value="Yes" id="choice_5_22_0" onchange="gformToggleRadioOther( this )">
<label for="choice_5_22_0" id="label_5_22_0" class="gform-field-label gform-field-label--type-inline">Yes</label>
</div>
<div class="gchoice gchoice_5_22_1">
<input class="gfield-choice-input" name="input_22" type="radio" value="No" id="choice_5_22_1" onchange="gformToggleRadioOther( this )">
<label for="choice_5_22_1" id="label_5_22_1" class="gform-field-label gform-field-label--type-inline">No</label>
</div>
</div>
</div>
</fieldset>
<div id="field_5_23"
class="gfield gfield--type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible"
data-js-reload="field_5_23">If you are not, did you know there is an online demonstration on the Asthma UK website or you could pop in and see our practice nurse for more advice.</div>
<fieldset id="field_5_24" class="gfield gfield--type-radio gfield--type-choice gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible" data-js-reload="field_5_24">
<legend class="gfield_label gform-field-label">8. Have you ever smoked?</legend>
<div class="ginput_container ginput_container_radio">
<div class="gfield_radio" id="input_5_24">
<div class="gchoice gchoice_5_24_0">
<input class="gfield-choice-input" name="input_24" type="radio" value="Yes" id="choice_5_24_0" onchange="gformToggleRadioOther( this )">
<label for="choice_5_24_0" id="label_5_24_0" class="gform-field-label gform-field-label--type-inline">Yes</label>
</div>
<div class="gchoice gchoice_5_24_1">
<input class="gfield-choice-input" name="input_24" type="radio" value="No" id="choice_5_24_1" onchange="gformToggleRadioOther( this )">
<label for="choice_5_24_1" id="label_5_24_1" class="gform-field-label gform-field-label--type-inline">No</label>
</div>
</div>
</div>
</fieldset>
<div id="field_5_25"
class="gfield gfield--type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible"
data-js-reload="field_5_25">If 'Yes', please answer the following:</div>
<fieldset id="field_5_26" class="gfield gfield--type-radio gfield--type-choice gfield--width-third field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible"
data-js-reload="field_5_26">
<legend class="gfield_label gform-field-label">Do you smoke now?</legend>
<div class="ginput_container ginput_container_radio">
<div class="gfield_radio" id="input_5_26">
<div class="gchoice gchoice_5_26_0">
<input class="gfield-choice-input" name="input_26" type="radio" value="Yes" id="choice_5_26_0" onchange="gformToggleRadioOther( this )">
<label for="choice_5_26_0" id="label_5_26_0" class="gform-field-label gform-field-label--type-inline">Yes</label>
</div>
<div class="gchoice gchoice_5_26_1">
<input class="gfield-choice-input" name="input_26" type="radio" value="No" id="choice_5_26_1" onchange="gformToggleRadioOther( this )">
<label for="choice_5_26_1" id="label_5_26_1" class="gform-field-label gform-field-label--type-inline">No</label>
</div>
</div>
</div>
</fieldset>
<div id="field_5_27" class="gfield gfield--type-text gfield--width-third field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible" data-js-reload="field_5_27"><label
class="gfield_label gform-field-label" for="input_5_27">If 'Yes' how many do you smoke each day?</label>
<div class="ginput_container ginput_container_text"><input name="input_27" id="input_5_27" type="text" value="" class="large" aria-invalid="false"> </div>
</div>
<div id="field_5_28" class="gfield gfield--type-text gfield--width-third field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible" data-js-reload="field_5_28"><label
class="gfield_label gform-field-label" for="input_5_28">If 'No' when did you quit?</label>
<div class="ginput_container ginput_container_text"><input name="input_28" id="input_5_28" type="text" value="" class="large" aria-invalid="false"> </div>
</div>
<fieldset id="field_5_30" class="gfield gfield--type-radio gfield--type-choice gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible" data-js-reload="field_5_30">
<legend class="gfield_label gform-field-label">There are plenty of options available to help you quit. Is this something you would like us to contact you about?</legend>
<div class="ginput_container ginput_container_radio">
<div class="gfield_radio" id="input_5_30">
<div class="gchoice gchoice_5_30_0">
<input class="gfield-choice-input" name="input_30" type="radio" value="Yes" id="choice_5_30_0" onchange="gformToggleRadioOther( this )">
<label for="choice_5_30_0" id="label_5_30_0" class="gform-field-label gform-field-label--type-inline">Yes</label>
</div>
<div class="gchoice gchoice_5_30_1">
<input class="gfield-choice-input" name="input_30" type="radio" value="No" id="choice_5_30_1" onchange="gformToggleRadioOther( this )">
<label for="choice_5_30_1" id="label_5_30_1" class="gform-field-label gform-field-label--type-inline">No</label>
</div>
</div>
</div>
</fieldset>
</div>
</div>
<div class="gform_footer top_label"> <input type="submit" id="gform_submit_button_5" class="gform_button button" value="Send"
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onkeypress="if( event.keyCode == 13 ){ if(window["gf_submitting_5"]){return false;} if( !jQuery("#gform_5")[0].checkValidity || jQuery("#gform_5")[0].checkValidity()){window["gf_submitting_5"]=true;} jQuery("#gform_5").trigger("submit",[true]); }">
<input type="hidden" class="gform_hidden" name="is_submit_5" value="1">
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<input type="hidden" class="gform_hidden" name="gform_source_page_number_5" id="gform_source_page_number_5" value="1">
<input type="hidden" name="gform_field_values" value="">
</div>
</form>POST /
<form method="post" enctype="multipart/form-data" id="gform_6" action="/" data-formid="6" novalidate="">
<div class="gform-body gform_body">
<div id="gform_fields_6" class="gform_fields top_label form_sublabel_below description_below validation_below">
<div id="field_6_1" class="gfield gfield--type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible"
data-js-reload="field_6_1">
<div class="frm-title">Change of Contact Details</div>
</div>
<div id="field_6_3" class="gfield gfield--type-select gfield--width-third gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible" data-js-reload="field_6_3">
<label class="gfield_label gform-field-label" for="input_6_3">Title<span class="gfield_required"><span class="gfield_required gfield_required_text">(Required)</span></span></label>
<div class="ginput_container ginput_container_select"><select name="input_3" id="input_6_3" class="large gfield_select" aria-required="true" aria-invalid="false">
<option value="Mr">Mr</option>
<option value="Mrs">Mrs</option>
<option value="Miss">Miss</option>
<option value="Ms">Ms</option>
<option value="Dr">Dr</option>
<option value="Prof">Prof</option>
</select></div>
</div>
<div id="field_6_4" class="gfield gfield--type-text gfield--width-third gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible" data-js-reload="field_6_4">
<label class="gfield_label gform-field-label" for="input_6_4">First Name(s)<span class="gfield_required"><span class="gfield_required gfield_required_text">(Required)</span></span></label>
<div class="ginput_container ginput_container_text"><input name="input_4" id="input_6_4" type="text" value="" class="large" aria-required="true" aria-invalid="false"> </div>
</div>
<div id="field_6_5" class="gfield gfield--type-text gfield--width-third gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible" data-js-reload="field_6_5">
<label class="gfield_label gform-field-label" for="input_6_5">Surname:<span class="gfield_required"><span class="gfield_required gfield_required_text">(Required)</span></span></label>
<div class="ginput_container ginput_container_text"><input name="input_5" id="input_6_5" type="text" value="" class="large" aria-required="true" aria-invalid="false"> </div>
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<fieldset id="field_6_6" class="gfield gfield--type-radio gfield--type-choice gfield--width-third gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible"
data-js-reload="field_6_6">
<legend class="gfield_label gform-field-label">Sex<span class="gfield_required"><span class="gfield_required gfield_required_text">(Required)</span></span></legend>
<div class="ginput_container ginput_container_radio">
<div class="gfield_radio" id="input_6_6">
<div class="gchoice gchoice_6_6_0">
<input class="gfield-choice-input" name="input_6" type="radio" value="Female" id="choice_6_6_0" onchange="gformToggleRadioOther( this )">
<label for="choice_6_6_0" id="label_6_6_0" class="gform-field-label gform-field-label--type-inline">Female</label>
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<div class="gchoice gchoice_6_6_1">
<input class="gfield-choice-input" name="input_6" type="radio" value="Male" id="choice_6_6_1" onchange="gformToggleRadioOther( this )">
<label for="choice_6_6_1" id="label_6_6_1" class="gform-field-label gform-field-label--type-inline">Male</label>
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<div id="field_6_7"
class="gfield gfield--type-date gfield--input-type-datepicker gfield--datepicker-default-icon gfield--width-third field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible"
data-js-reload="field_6_7"><label class="gfield_label gform-field-label" for="input_6_7">Date of Birth</label>
<div class="ginput_container ginput_container_date">
<input name="input_7" id="input_6_7" type="text" value="" class="datepicker gform-datepicker dmy datepicker_with_icon gdatepicker_with_icon hasDatepicker initialized" placeholder="dd/mm/yyyy" aria-describedby="input_6_7_date_format"
aria-invalid="false"><img class="ui-datepicker-trigger" src="https://nhsgp.net/wp-content/plugins/gravityforms/images/datepicker/datepicker.svg" alt="Select date" title="Select date">
<span id="input_6_7_date_format" class="screen-reader-text">DD slash MM slash YYYY</span>
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<input type="hidden" id="gforms_calendar_icon_input_6_7" class="gform_hidden" value="https://nhsgp.net/wp-content/plugins/gravityforms/images/datepicker/datepicker.svg">
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<div id="field_6_8" class="gfield gfield--type-text gfield--width-third field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible" data-js-reload="field_6_8"><label
class="gfield_label gform-field-label" for="input_6_8">Previous Surname</label>
<div class="ginput_container ginput_container_text"><input name="input_8" id="input_6_8" type="text" value="" class="large" aria-invalid="false"> </div>
</div>
<div id="field_6_9" class="gfield gfield--type-text gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible" data-js-reload="field_6_9"><label
class="gfield_label gform-field-label" for="input_6_9">NHS No</label>
<div class="ginput_container ginput_container_text"><input name="input_9" id="input_6_9" type="text" value="" class="large" aria-invalid="false"> </div>
</div>
<div id="field_6_10" class="gfield gfield--type-email gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible" data-js-reload="field_6_10">
<label class="gfield_label gform-field-label" for="input_6_10">Email:<span class="gfield_required"><span class="gfield_required gfield_required_text">(Required)</span></span></label>
<div class="ginput_container ginput_container_email">
<input name="input_10" id="input_6_10" type="email" value="" class="large" aria-required="true" aria-invalid="false">
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<div id="field_6_11" class="gfield gfield--type-textarea gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible" data-js-reload="field_6_11"><label
class="gfield_label gform-field-label" for="input_6_11">Old Address</label>
<div class="ginput_container ginput_container_textarea"><textarea name="input_11" id="input_6_11" class="textarea small" aria-invalid="false" rows="10" cols="50"></textarea></div>
</div>
<div id="field_6_12" class="gfield gfield--type-text gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible" data-js-reload="field_6_12">
<label class="gfield_label gform-field-label" for="input_6_12">Old Postcode<span class="gfield_required"><span class="gfield_required gfield_required_text">(Required)</span></span></label>
<div class="ginput_container ginput_container_text"><input name="input_12" id="input_6_12" type="text" value="" class="large" aria-required="true" aria-invalid="false"> </div>
</div>
<div id="field_6_13" class="gfield gfield--type-phone gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible" data-js-reload="field_6_13">
<label class="gfield_label gform-field-label" for="input_6_13">Old Home Tel<span class="gfield_required"><span class="gfield_required gfield_required_text">(Required)</span></span></label>
<div class="ginput_container ginput_container_phone"><input name="input_13" id="input_6_13" type="tel" value="" class="large" aria-required="true" aria-invalid="false"></div>
</div>
<div id="field_6_14" class="gfield gfield--type-textarea gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible"
data-js-reload="field_6_14"><label class="gfield_label gform-field-label" for="input_6_14">New Address<span class="gfield_required"><span class="gfield_required gfield_required_text">(Required)</span></span></label>
<div class="ginput_container ginput_container_textarea"><textarea name="input_14" id="input_6_14" class="textarea small"
placeholder="Note: If your new address falls outside of our catchment area, you will need to register with a new GP and we will be contacting you regarding this matter." aria-required="true" aria-invalid="false" rows="10"
cols="50"></textarea></div>
</div>
<div id="field_6_15" class="gfield gfield--type-text gfield--width-quarter field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible" data-js-reload="field_6_15"><label
class="gfield_label gform-field-label" for="input_6_15">New Postcode</label>
<div class="ginput_container ginput_container_text"><input name="input_15" id="input_6_15" type="text" value="" class="large" aria-invalid="false"> </div>
</div>
<div id="field_6_16" class="gfield gfield--type-phone gfield--width-quarter gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible"
data-js-reload="field_6_16"><label class="gfield_label gform-field-label" for="input_6_16">New Tel<span class="gfield_required"><span class="gfield_required gfield_required_text">(Required)</span></span></label>
<div class="ginput_container ginput_container_phone"><input name="input_16" id="input_6_16" type="tel" value="" class="large" aria-required="true" aria-invalid="false"></div>
</div>
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class="gfield_label gform-field-label" for="input_6_17">Mobile</label>
<div class="ginput_container ginput_container_phone"><input name="input_17" id="input_6_17" type="tel" value="" class="large" aria-invalid="false"></div>
</div>
<div id="field_6_18" class="gfield gfield--type-phone gfield--width-quarter field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible" data-js-reload="field_6_18"><label
class="gfield_label gform-field-label" for="input_6_18">Work Tel</label>
<div class="ginput_container ginput_container_phone"><input name="input_18" id="input_6_18" type="tel" value="" class="large" aria-invalid="false"></div>
</div>
<fieldset id="field_6_19" class="gfield gfield--type-radio gfield--type-choice gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible"
data-js-reload="field_6_19">
<legend class="gfield_label gform-field-label">Are you a student?<span class="gfield_required"><span class="gfield_required gfield_required_text">(Required)</span></span></legend>
<div class="ginput_container ginput_container_radio">
<div class="gfield_radio" id="input_6_19">
<div class="gchoice gchoice_6_19_0">
<input class="gfield-choice-input" name="input_19" type="radio" value="I am NOT a student" id="choice_6_19_0" onchange="gformToggleRadioOther( this )">
<label for="choice_6_19_0" id="label_6_19_0" class="gform-field-label gform-field-label--type-inline">I am NOT a student</label>
</div>
<div class="gchoice gchoice_6_19_1">
<input class="gfield-choice-input" name="input_19" type="radio" value="I AM a student" id="choice_6_19_1" onchange="gformToggleRadioOther( this )">
<label for="choice_6_19_1" id="label_6_19_1" class="gform-field-label gform-field-label--type-inline">I AM a student</label>
</div>
</div>
</div>
</fieldset>
<div id="field_6_20" class="gfield gfield--type-textarea gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible" data-js-reload="field_6_20"><label
class="gfield_label gform-field-label" for="input_6_20">Other members of your family requiring a change of address (if registered here)</label>
<div class="ginput_container ginput_container_textarea"><textarea name="input_20" id="input_6_20" class="textarea small" placeholder="Include full Name(s) & Telephone Number(s)" aria-invalid="false" rows="10" cols="50"></textarea></div>
</div>
</div>
</div>
<div class="gform_footer top_label"> <input type="submit" id="gform_submit_button_6" class="gform_button button" value="Send"
onclick="if(window["gf_submitting_6"]){return false;} if( !jQuery("#gform_6")[0].checkValidity || jQuery("#gform_6")[0].checkValidity()){window["gf_submitting_6"]=true;} "
onkeypress="if( event.keyCode == 13 ){ if(window["gf_submitting_6"]){return false;} if( !jQuery("#gform_6")[0].checkValidity || jQuery("#gform_6")[0].checkValidity()){window["gf_submitting_6"]=true;} jQuery("#gform_6").trigger("submit",[true]); }">
<input type="hidden" class="gform_hidden" name="is_submit_6" value="1">
<input type="hidden" class="gform_hidden" name="gform_submit" value="6">
<input type="hidden" class="gform_hidden" name="gform_unique_id" value="">
<input type="hidden" class="gform_hidden" name="state_6"
value="WyJ7XCI2XCI6W1wiNjg1YTcwYWQ0OWRjMzRjMDQ1OWUyZDRlM2Y2NGM0ZDlcIixcIjk0NzUwNmMxNTJlZWRiMWFjOWRkMWE1OGI1YmRmMTc1XCJdLFwiMTlcIjpbXCI2NDM1MzdkNGE3ZDFjMzcyNDg5YWMxYmQ5YzRmNzcyNFwiLFwiOTIyMjFiOTJhNDNlY2RhZTVkMDVlZTBmZDI4Mjc4YzNcIl19IiwiZDk1NjcxOGI4MmU4MGExYTdkOWQ5ZWExZTRiZjVhMjYiXQ==">
<input type="hidden" class="gform_hidden" name="gform_target_page_number_6" id="gform_target_page_number_6" value="0">
<input type="hidden" class="gform_hidden" name="gform_source_page_number_6" id="gform_source_page_number_6" value="1">
<input type="hidden" name="gform_field_values" value="">
</div>
</form>POST /
<form method="post" enctype="multipart/form-data" id="gform_9" action="/" data-formid="9" novalidate="">
<div class="gform-body gform_body">
<div id="gform_fields_9" class="gform_fields top_label form_sublabel_below description_below validation_below">
<div id="field_9_1" class="gfield gfield--type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible"
data-js-reload="field_9_1">
<div class="frm-title">Comments and Suggestions Form</div>
<div class="frm-desc">This is the easiest way to make a complaint or leave a comment for us.</div>
</div>
<div id="field_9_21"
class="gfield gfield--type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible"
data-js-reload="field_9_21">
<div class="frm-info">
<h5> What kind of comment would you like to send? Remember this form is not for medical matters. </h5>
</div>
</div>
<fieldset id="field_9_6" class="gfield gfield--type-radio gfield--type-choice gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible" data-js-reload="field_9_6">
<legend class="gfield_label gform-field-label">Your comment is:</legend>
<div class="ginput_container ginput_container_radio">
<div class="gfield_radio" id="input_9_6">
<div class="gchoice gchoice_9_6_0">
<input class="gfield-choice-input" name="input_6" type="radio" value="A suggestion" id="choice_9_6_0" onchange="gformToggleRadioOther( this )">
<label for="choice_9_6_0" id="label_9_6_0" class="gform-field-label gform-field-label--type-inline">A suggestion</label>
</div>
<div class="gchoice gchoice_9_6_1">
<input class="gfield-choice-input" name="input_6" type="radio" value="Praise" id="choice_9_6_1" onchange="gformToggleRadioOther( this )">
<label for="choice_9_6_1" id="label_9_6_1" class="gform-field-label gform-field-label--type-inline">Praise</label>
</div>
<div class="gchoice gchoice_9_6_2">
<input class="gfield-choice-input" name="input_6" type="radio" value="Regarding a problem" id="choice_9_6_2" onchange="gformToggleRadioOther( this )">
<label for="choice_9_6_2" id="label_9_6_2" class="gform-field-label gform-field-label--type-inline">Regarding a problem</label>
</div>
<div class="gchoice gchoice_9_6_3">
<input class="gfield-choice-input" name="input_6" type="radio" value="Other" id="choice_9_6_3" onchange="gformToggleRadioOther( this )">
<label for="choice_9_6_3" id="label_9_6_3" class="gform-field-label gform-field-label--type-inline">Other</label>
</div>
</div>
</div>
</fieldset>
<div id="field_9_11" class="gfield gfield--type-textarea gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible" data-js-reload="field_9_11"><label
class="gfield_label gform-field-label" for="input_9_11">What would you like to say? Enter your comments in the space below</label>
<div class="ginput_container ginput_container_textarea"><textarea name="input_11" id="input_9_11" class="textarea small" aria-invalid="false" rows="10" cols="50"></textarea></div>
</div>
<div id="field_9_22"
class="gfield gfield--type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible"
data-js-reload="field_9_22">
<h5>Your contact details </h5>
</div>
<div id="field_9_12" class="gfield gfield--type-text gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible" data-js-reload="field_9_12"><label
class="gfield_label gform-field-label" for="input_9_12">Your name:</label>
<div class="ginput_container ginput_container_text"><input name="input_12" id="input_9_12" type="text" value="" class="large" aria-invalid="false"> </div>
</div>
<div id="field_9_23" class="gfield gfield--type-email gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible" data-js-reload="field_9_23"><label
class="gfield_label gform-field-label" for="input_9_23">Your email:</label>
<div class="ginput_container ginput_container_email">
<input name="input_23" id="input_9_23" type="email" value="" class="large" aria-invalid="false">
</div>
</div>
<div id="field_9_17" class="gfield gfield--type-phone gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible" data-js-reload="field_9_17"><label
class="gfield_label gform-field-label" for="input_9_17">Your telephone number:</label>
<div class="ginput_container ginput_container_phone"><input name="input_17" id="input_9_17" type="tel" value="" class="large" aria-invalid="false"></div>
</div>
<fieldset id="field_9_25" class="gfield gfield--type-checkbox gfield--type-choice gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible"
data-js-reload="field_9_25">
<legend class="gfield_label gform-field-label gfield_label_before_complex">Do you agree to be contacted regarding this matter?<span class="gfield_required"><span class="gfield_required gfield_required_text">(Required)</span></span></legend>
<div class="ginput_container ginput_container_checkbox">
<div class="gfield_checkbox" id="input_9_25">
<div class="gchoice gchoice_9_25_1">
<input class="gfield-choice-input" name="input_25.1" type="checkbox" value="Yes, I agree that the practice may contact me regarding this matter" id="choice_9_25_1">
<label for="choice_9_25_1" id="label_9_25_1" class="gform-field-label gform-field-label--type-inline">Yes, I agree that the practice may contact me regarding this matter</label>
</div>
</div>
</div>
</fieldset>
</div>
</div>
<div class="gform_footer top_label"> <input type="submit" id="gform_submit_button_9" class="gform_button button" value="Send"
onclick="if(window["gf_submitting_9"]){return false;} if( !jQuery("#gform_9")[0].checkValidity || jQuery("#gform_9")[0].checkValidity()){window["gf_submitting_9"]=true;} "
onkeypress="if( event.keyCode == 13 ){ if(window["gf_submitting_9"]){return false;} if( !jQuery("#gform_9")[0].checkValidity || jQuery("#gform_9")[0].checkValidity()){window["gf_submitting_9"]=true;} jQuery("#gform_9").trigger("submit",[true]); }">
<input type="hidden" class="gform_hidden" name="is_submit_9" value="1">
<input type="hidden" class="gform_hidden" name="gform_submit" value="9">
<input type="hidden" class="gform_hidden" name="gform_unique_id" value="">
<input type="hidden" class="gform_hidden" name="state_9"
value="WyJ7XCI2XCI6W1wiYTQxYTljNDUyMThlMWIyODYxNTA3ODAwYTU0ZGU1ZDlcIixcIjlkZjBjYWRhNTlhMGFjNDc0YmI0NTYyYTNlYzlmYTk4XCIsXCI4Nzk2NDg1MWJhNzhhY2RmMjcyYzkyMWQ3ZTBiYjYyNFwiLFwiNWM2YmE1MWQ3MWIwYjc3Y2E4MWQ5YmNiMWIzZWYyOTVcIl19IiwiOWUzN2I0NWY4YzM1YTRjZjA0ZmZkMTlhMzQyYzNiYzgiXQ==">
<input type="hidden" class="gform_hidden" name="gform_target_page_number_9" id="gform_target_page_number_9" value="0">
<input type="hidden" class="gform_hidden" name="gform_source_page_number_9" id="gform_source_page_number_9" value="1">
<input type="hidden" name="gform_field_values" value="">
</div>
</form>POST /
<form method="post" enctype="multipart/form-data" id="gform_10" action="/" data-formid="10" novalidate="">
<div class="gform-body gform_body">
<div id="gform_fields_10" class="gform_fields top_label form_sublabel_below description_below validation_below">
<div id="field_10_1" class="gfield gfield--type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible"
data-js-reload="field_10_1">
<div class="frm-title">New Patient Health Questionnaire for Adults</div>
</div>
<div id="field_10_21"
class="gfield gfield--type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible"
data-js-reload="field_10_21">
<div class="frm-info">
<h5> Your contact details </h5>
</div>
</div>
<fieldset id="field_10_6" class="gfield gfield--type-radio gfield--type-choice gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible" data-js-reload="field_10_6">
<legend class="gfield_label gform-field-label">Title:</legend>
<div class="ginput_container ginput_container_radio">
<div class="gfield_radio" id="input_10_6">
<div class="gchoice gchoice_10_6_0">
<input class="gfield-choice-input" name="input_6" type="radio" value="Mr." id="choice_10_6_0" onchange="gformToggleRadioOther( this )">
<label for="choice_10_6_0" id="label_10_6_0" class="gform-field-label gform-field-label--type-inline">Mr.</label>
</div>
<div class="gchoice gchoice_10_6_1">
<input class="gfield-choice-input" name="input_6" type="radio" value="Mrs." id="choice_10_6_1" onchange="gformToggleRadioOther( this )">
<label for="choice_10_6_1" id="label_10_6_1" class="gform-field-label gform-field-label--type-inline">Mrs.</label>
</div>
<div class="gchoice gchoice_10_6_2">
<input class="gfield-choice-input" name="input_6" type="radio" value="Miss." id="choice_10_6_2" onchange="gformToggleRadioOther( this )">
<label for="choice_10_6_2" id="label_10_6_2" class="gform-field-label gform-field-label--type-inline">Miss.</label>
</div>
<div class="gchoice gchoice_10_6_3">
<input class="gfield-choice-input" name="input_6" type="radio" value="Ms." id="choice_10_6_3" onchange="gformToggleRadioOther( this )">
<label for="choice_10_6_3" id="label_10_6_3" class="gform-field-label gform-field-label--type-inline">Ms.</label>
</div>
</div>
</div>
</fieldset>
<div id="field_10_26" class="gfield gfield--type-text gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible"
data-js-reload="field_10_26"><label class="gfield_label gform-field-label" for="input_10_26">First name:<span class="gfield_required"><span class="gfield_required gfield_required_text">(Required)</span></span></label>
<div class="ginput_container ginput_container_text"><input name="input_26" id="input_10_26" type="text" value="" class="large" aria-required="true" aria-invalid="false"> </div>
</div>
<div id="field_10_27" class="gfield gfield--type-text gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible"
data-js-reload="field_10_27"><label class="gfield_label gform-field-label" for="input_10_27">Surname(s):<span class="gfield_required"><span class="gfield_required gfield_required_text">(Required)</span></span></label>
<div class="ginput_container ginput_container_text"><input name="input_27" id="input_10_27" type="text" value="" class="large" aria-required="true" aria-invalid="false"> </div>
</div>
<div id="field_10_28" class="gfield gfield--type-text gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible" data-js-reload="field_10_28"><label
class="gfield_label gform-field-label" for="input_10_28">Previous surname</label>
<div class="ginput_container ginput_container_text"><input name="input_28" id="input_10_28" type="text" value="" class="large" aria-invalid="false"> </div>
</div>
<div id="field_10_29" class="gfield gfield--type-text gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible" data-js-reload="field_10_29"><label
class="gfield_label gform-field-label" for="input_10_29">Occupation:</label>
<div class="ginput_container ginput_container_text"><input name="input_29" id="input_10_29" type="text" value="" class="large" aria-invalid="false"> </div>
</div>
<div id="field_10_30"
class="gfield gfield--type-date gfield--input-type-datepicker gfield--datepicker-default-icon gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible"
data-js-reload="field_10_30"><label class="gfield_label gform-field-label" for="input_10_30">Date of birth:<span class="gfield_required"><span class="gfield_required gfield_required_text">(Required)</span></span></label>
<div class="ginput_container ginput_container_date">
<input name="input_30" id="input_10_30" type="text" value="" class="datepicker gform-datepicker dmy datepicker_with_icon gdatepicker_with_icon hasDatepicker initialized" placeholder="dd/mm/yyyy" aria-describedby="input_10_30_date_format"
aria-invalid="false" aria-required="true"><img class="ui-datepicker-trigger" src="https://nhsgp.net/wp-content/plugins/gravityforms/images/datepicker/datepicker.svg" alt="Select date" title="Select date">
<span id="input_10_30_date_format" class="screen-reader-text">DD slash MM slash YYYY</span>
</div>
<input type="hidden" id="gforms_calendar_icon_input_10_30" class="gform_hidden" value="https://nhsgp.net/wp-content/plugins/gravityforms/images/datepicker/datepicker.svg">
</div>
<div id="field_10_11" class="gfield gfield--type-textarea gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible"
data-js-reload="field_10_11"><label class="gfield_label gform-field-label" for="input_10_11">Address:<span class="gfield_required"><span class="gfield_required gfield_required_text">(Required)</span></span></label>
<div class="ginput_container ginput_container_textarea"><textarea name="input_11" id="input_10_11" class="textarea small" aria-required="true" aria-invalid="false" rows="10" cols="50"></textarea></div>
</div>
<div id="field_10_12" class="gfield gfield--type-text gfield--width-third field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible" data-js-reload="field_10_12"><label
class="gfield_label gform-field-label" for="input_10_12">Postcode:</label>
<div class="ginput_container ginput_container_text"><input name="input_12" id="input_10_12" type="text" value="" class="large" aria-invalid="false"> </div>
</div>
<div id="field_10_31" class="gfield gfield--type-email gfield--width-two-thirds field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible" data-js-reload="field_10_31"><label
class="gfield_label gform-field-label" for="input_10_31">Email:</label>
<div class="ginput_container ginput_container_email">
<input name="input_31" id="input_10_31" type="email" value="" class="large" aria-invalid="false">
</div>
</div>
<div id="field_10_17" class="gfield gfield--type-phone gfield--width-third gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible"
data-js-reload="field_10_17"><label class="gfield_label gform-field-label" for="input_10_17">Telephone:<span class="gfield_required"><span class="gfield_required gfield_required_text">(Required)</span></span></label>
<div class="ginput_container ginput_container_phone"><input name="input_17" id="input_10_17" type="tel" value="" class="large" aria-required="true" aria-invalid="false"></div>
</div>
<div id="field_10_32" class="gfield gfield--type-phone gfield--width-third field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible" data-js-reload="field_10_32"><label
class="gfield_label gform-field-label" for="input_10_32">Work tel:</label>
<div class="ginput_container ginput_container_phone"><input name="input_32" id="input_10_32" type="tel" value="" class="large" aria-invalid="false"></div>
</div>
<div id="field_10_33" class="gfield gfield--type-phone gfield--width-third field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible" data-js-reload="field_10_33"><label
class="gfield_label gform-field-label" for="input_10_33">Mobile:</label>
<div class="ginput_container ginput_container_phone"><input name="input_33" id="input_10_33" type="tel" value="" class="large" aria-invalid="false"></div>
</div>
<div id="field_10_34"
class="gfield gfield--type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible"
data-js-reload="field_10_34">
<h5> Information about you </h5>
</div>
<div id="field_10_35" class="gfield gfield--type-text gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible"
data-js-reload="field_10_35"><label class="gfield_label gform-field-label" for="input_10_35">What is your height?<span class="gfield_required"><span class="gfield_required gfield_required_text">(Required)</span></span></label>
<div class="ginput_container ginput_container_text"><input name="input_35" id="input_10_35" type="text" value="" class="large" aria-required="true" aria-invalid="false"> </div>
</div>
<div id="field_10_36" class="gfield gfield--type-text gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible"
data-js-reload="field_10_36"><label class="gfield_label gform-field-label" for="input_10_36">What is your weight?<span class="gfield_required"><span class="gfield_required gfield_required_text">(Required)</span></span></label>
<div class="ginput_container ginput_container_text"><input name="input_36" id="input_10_36" type="text" value="" class="large" aria-required="true" aria-invalid="false"> </div>
</div>
<div id="field_10_37" class="gfield gfield--type-text gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible"
data-js-reload="field_10_37"><label class="gfield_label gform-field-label" for="input_10_37">What is your first language?<span class="gfield_required"><span class="gfield_required gfield_required_text">(Required)</span></span></label>
<div class="ginput_container ginput_container_text"><input name="input_37" id="input_10_37" type="text" value="" class="large" aria-required="true" aria-invalid="false"> </div>
</div>
<fieldset id="field_10_38" class="gfield gfield--type-radio gfield--type-choice gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible"
data-js-reload="field_10_38">
<legend class="gfield_label gform-field-label">Do you need an interpreter?<span class="gfield_required"><span class="gfield_required gfield_required_text">(Required)</span></span></legend>
<div class="ginput_container ginput_container_radio">
<div class="gfield_radio" id="input_10_38">
<div class="gchoice gchoice_10_38_0">
<input class="gfield-choice-input" name="input_38" type="radio" value="Yes" id="choice_10_38_0" onchange="gformToggleRadioOther( this )">
<label for="choice_10_38_0" id="label_10_38_0" class="gform-field-label gform-field-label--type-inline">Yes</label>
</div>
<div class="gchoice gchoice_10_38_1">
<input class="gfield-choice-input" name="input_38" type="radio" value="No" id="choice_10_38_1" onchange="gformToggleRadioOther( this )">
<label for="choice_10_38_1" id="label_10_38_1" class="gform-field-label gform-field-label--type-inline">No</label>
</div>
</div>
</div>
</fieldset>
<div id="field_10_39" class="gfield gfield--type-select gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible" data-js-reload="field_10_39"><label
class="gfield_label gform-field-label" for="input_10_39">Ethnic Group</label>
<div class="ginput_container ginput_container_select"><select name="input_39" id="input_10_39" class="large gfield_select" aria-invalid="false">
<option value="British">British</option>
<option value="Irish">Irish</option>
<option value="Caribbean">Caribbean</option>
<option value="African">African</option>
<option value="Indian">Indian</option>
<option value="Pakistani">Pakistani</option>
<option value="Chinese">Chinese</option>
<option value="White + Black Caribbean">White + Black Caribbean</option>
<option value="White + Black African">White + Black African</option>
<option value="White + Asian">White + Asian</option>
<option value="Other">Other</option>
</select></div>
</div>
<div id="field_10_40" class="gfield gfield--type-text gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible" data-js-reload="field_10_40"><label
class="gfield_label gform-field-label" for="input_10_40">If other, please specify</label>
<div class="ginput_container ginput_container_text"><input name="input_40" id="input_10_40" type="text" value="" class="large" aria-invalid="false"> </div>
</div>
<div id="field_10_41"
class="gfield gfield--type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible"
data-js-reload="field_10_41">
<h5> Previous GP </h5>
</div>
<div id="field_10_42" class="gfield gfield--type-textarea gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible" data-js-reload="field_10_42"><label
class="gfield_label gform-field-label" for="input_10_42">Name and Address of Previous GP</label>
<div class="ginput_container ginput_container_textarea"><textarea name="input_42" id="input_10_42" class="textarea small" aria-invalid="false" rows="10" cols="50"></textarea></div>
</div>
<fieldset id="field_10_43" class="gfield gfield--type-checkbox gfield--type-choice gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible"
data-js-reload="field_10_43">
<legend class="gfield_label gform-field-label gfield_label_before_complex">Proof of Identity and Address Provided</legend>
<div class="ginput_container ginput_container_checkbox">
<div class="gfield_checkbox" id="input_10_43">
<div class="gchoice gchoice_10_43_1">
<input class="gfield-choice-input" name="input_43.1" type="checkbox" value="Birth Certificate" id="choice_10_43_1">
<label for="choice_10_43_1" id="label_10_43_1" class="gform-field-label gform-field-label--type-inline">Birth Certificate</label>
</div>
<div class="gchoice gchoice_10_43_2">
<input class="gfield-choice-input" name="input_43.2" type="checkbox" value="Driving Licence" id="choice_10_43_2">
<label for="choice_10_43_2" id="label_10_43_2" class="gform-field-label gform-field-label--type-inline">Driving Licence</label>
</div>
<div class="gchoice gchoice_10_43_3">
<input class="gfield-choice-input" name="input_43.3" type="checkbox" value="Passport" id="choice_10_43_3">
<label for="choice_10_43_3" id="label_10_43_3" class="gform-field-label gform-field-label--type-inline">Passport</label>
</div>
<div class="gchoice gchoice_10_43_4">
<input class="gfield-choice-input" name="input_43.4" type="checkbox" value="Utility Bill" id="choice_10_43_4">
<label for="choice_10_43_4" id="label_10_43_4" class="gform-field-label gform-field-label--type-inline">Utility Bill</label>
</div>
<div class="gchoice gchoice_10_43_5">
<input class="gfield-choice-input" name="input_43.5" type="checkbox" value="Allowance Book" id="choice_10_43_5">
<label for="choice_10_43_5" id="label_10_43_5" class="gform-field-label gform-field-label--type-inline">Allowance Book</label>
</div>
<div class="gchoice gchoice_10_43_6">
<input class="gfield-choice-input" name="input_43.6" type="checkbox" value="Solicitor's Letter" id="choice_10_43_6">
<label for="choice_10_43_6" id="label_10_43_6" class="gform-field-label gform-field-label--type-inline">Solicitor's Letter</label>
</div>
<div class="gchoice gchoice_10_43_7">
<input class="gfield-choice-input" name="input_43.7" type="checkbox" value="Offer of Tenancy" id="choice_10_43_7">
<label for="choice_10_43_7" id="label_10_43_7" class="gform-field-label gform-field-label--type-inline">Offer of Tenancy</label>
</div>
<div class="gchoice gchoice_10_43_8">
<input class="gfield-choice-input" name="input_43.8" type="checkbox" value="Other" id="choice_10_43_8">
<label for="choice_10_43_8" id="label_10_43_8" class="gform-field-label gform-field-label--type-inline">Other</label>
</div>
</div>
</div>
</fieldset>
<div id="field_10_44"
class="gfield gfield--type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible"
data-js-reload="field_10_44">
<h5> Medical Information </h5>
</div>
<div id="field_10_45" class="gfield gfield--type-text gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible" data-js-reload="field_10_45"><label
class="gfield_label gform-field-label" for="input_10_45">Please list any serious illnesses / operations / accidents / disabilities (and for women any pregnancy related problems) and the year they took place:</label>
<div class="ginput_container ginput_container_text"><input name="input_45" id="input_10_45" type="text" value="" class="large" aria-invalid="false"> </div>
</div>
<div id="field_10_46"
class="gfield gfield--type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible"
data-js-reload="field_10_46">Have you ever suffered from? (tick as appropriate)</div>
<fieldset id="field_10_47" class="gfield gfield--type-radio gfield--type-choice gfield--width-third field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible"
data-js-reload="field_10_47">
<legend class="gfield_label gform-field-label">Epilepsy</legend>
<div class="ginput_container ginput_container_radio">
<div class="gfield_radio" id="input_10_47">
<div class="gchoice gchoice_10_47_0">
<input class="gfield-choice-input" name="input_47" type="radio" value="Yes" id="choice_10_47_0" onchange="gformToggleRadioOther( this )">
<label for="choice_10_47_0" id="label_10_47_0" class="gform-field-label gform-field-label--type-inline">Yes</label>
</div>
<div class="gchoice gchoice_10_47_1">
<input class="gfield-choice-input" name="input_47" type="radio" value="No" id="choice_10_47_1" onchange="gformToggleRadioOther( this )">
<label for="choice_10_47_1" id="label_10_47_1" class="gform-field-label gform-field-label--type-inline">No</label>
</div>
</div>
</div>
</fieldset>
<fieldset id="field_10_48" class="gfield gfield--type-radio gfield--type-choice gfield--width-third field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible"
data-js-reload="field_10_48">
<legend class="gfield_label gform-field-label">Heart Attack/Stroke</legend>
<div class="ginput_container ginput_container_radio">
<div class="gfield_radio" id="input_10_48">
<div class="gchoice gchoice_10_48_0">
<input class="gfield-choice-input" name="input_48" type="radio" value="Yes" id="choice_10_48_0" onchange="gformToggleRadioOther( this )">
<label for="choice_10_48_0" id="label_10_48_0" class="gform-field-label gform-field-label--type-inline">Yes</label>
</div>
<div class="gchoice gchoice_10_48_1">
<input class="gfield-choice-input" name="input_48" type="radio" value="No" id="choice_10_48_1" onchange="gformToggleRadioOther( this )">
<label for="choice_10_48_1" id="label_10_48_1" class="gform-field-label gform-field-label--type-inline">No</label>
</div>
</div>
</div>
</fieldset>
<fieldset id="field_10_49" class="gfield gfield--type-radio gfield--type-choice gfield--width-third field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible"
data-js-reload="field_10_49">
<legend class="gfield_label gform-field-label">High Blood Pressure</legend>
<div class="ginput_container ginput_container_radio">
<div class="gfield_radio" id="input_10_49">
<div class="gchoice gchoice_10_49_0">
<input class="gfield-choice-input" name="input_49" type="radio" value="Yes" id="choice_10_49_0" onchange="gformToggleRadioOther( this )">
<label for="choice_10_49_0" id="label_10_49_0" class="gform-field-label gform-field-label--type-inline">Yes</label>
</div>
<div class="gchoice gchoice_10_49_1">
<input class="gfield-choice-input" name="input_49" type="radio" value="No" id="choice_10_49_1" onchange="gformToggleRadioOther( this )">
<label for="choice_10_49_1" id="label_10_49_1" class="gform-field-label gform-field-label--type-inline">No</label>
</div>
</div>
</div>
</fieldset>
<fieldset id="field_10_50" class="gfield gfield--type-radio gfield--type-choice gfield--width-third field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible"
data-js-reload="field_10_50">
<legend class="gfield_label gform-field-label">Cancer</legend>
<div class="ginput_container ginput_container_radio">
<div class="gfield_radio" id="input_10_50">
<div class="gchoice gchoice_10_50_0">
<input class="gfield-choice-input" name="input_50" type="radio" value="Yes" id="choice_10_50_0" onchange="gformToggleRadioOther( this )">
<label for="choice_10_50_0" id="label_10_50_0" class="gform-field-label gform-field-label--type-inline">Yes</label>
</div>
<div class="gchoice gchoice_10_50_1">
<input class="gfield-choice-input" name="input_50" type="radio" value="No" id="choice_10_50_1" onchange="gformToggleRadioOther( this )">
<label for="choice_10_50_1" id="label_10_50_1" class="gform-field-label gform-field-label--type-inline">No</label>
</div>
</div>
</div>
</fieldset>
<fieldset id="field_10_52" class="gfield gfield--type-radio gfield--type-choice gfield--width-third field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible"
data-js-reload="field_10_52">
<legend class="gfield_label gform-field-label">Eczema/Hay Fever</legend>
<div class="ginput_container ginput_container_radio">
<div class="gfield_radio" id="input_10_52">
<div class="gchoice gchoice_10_52_0">
<input class="gfield-choice-input" name="input_52" type="radio" value="Yes" id="choice_10_52_0" onchange="gformToggleRadioOther( this )">
<label for="choice_10_52_0" id="label_10_52_0" class="gform-field-label gform-field-label--type-inline">Yes</label>
</div>
<div class="gchoice gchoice_10_52_1">
<input class="gfield-choice-input" name="input_52" type="radio" value="No" id="choice_10_52_1" onchange="gformToggleRadioOther( this )">
<label for="choice_10_52_1" id="label_10_52_1" class="gform-field-label gform-field-label--type-inline">No</label>
</div>
</div>
</div>
</fieldset>
<fieldset id="field_10_51" class="gfield gfield--type-radio gfield--type-choice gfield--width-third field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible"
data-js-reload="field_10_51">
<legend class="gfield_label gform-field-label">Blindness/Glaucoma</legend>
<div class="ginput_container ginput_container_radio">
<div class="gfield_radio" id="input_10_51">
<div class="gchoice gchoice_10_51_0">
<input class="gfield-choice-input" name="input_51" type="radio" value="Yes" id="choice_10_51_0" onchange="gformToggleRadioOther( this )">
<label for="choice_10_51_0" id="label_10_51_0" class="gform-field-label gform-field-label--type-inline">Yes</label>
</div>
<div class="gchoice gchoice_10_51_1">
<input class="gfield-choice-input" name="input_51" type="radio" value="No" id="choice_10_51_1" onchange="gformToggleRadioOther( this )">
<label for="choice_10_51_1" id="label_10_51_1" class="gform-field-label gform-field-label--type-inline">No</label>
</div>
</div>
</div>
</fieldset>
<fieldset id="field_10_53" class="gfield gfield--type-radio gfield--type-choice gfield--width-third field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible"
data-js-reload="field_10_53">
<legend class="gfield_label gform-field-label">Diabetes</legend>
<div class="ginput_container ginput_container_radio">
<div class="gfield_radio" id="input_10_53">
<div class="gchoice gchoice_10_53_0">
<input class="gfield-choice-input" name="input_53" type="radio" value="Yes" id="choice_10_53_0" onchange="gformToggleRadioOther( this )">
<label for="choice_10_53_0" id="label_10_53_0" class="gform-field-label gform-field-label--type-inline">Yes</label>
</div>
<div class="gchoice gchoice_10_53_1">
<input class="gfield-choice-input" name="input_53" type="radio" value="No" id="choice_10_53_1" onchange="gformToggleRadioOther( this )">
<label for="choice_10_53_1" id="label_10_53_1" class="gform-field-label gform-field-label--type-inline">No</label>
</div>
</div>
</div>
</fieldset>
<fieldset id="field_10_54" class="gfield gfield--type-radio gfield--type-choice gfield--width-third field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible"
data-js-reload="field_10_54">
<legend class="gfield_label gform-field-label">Depression</legend>
<div class="ginput_container ginput_container_radio">
<div class="gfield_radio" id="input_10_54">
<div class="gchoice gchoice_10_54_0">
<input class="gfield-choice-input" name="input_54" type="radio" value="Yes" id="choice_10_54_0" onchange="gformToggleRadioOther( this )">
<label for="choice_10_54_0" id="label_10_54_0" class="gform-field-label gform-field-label--type-inline">Yes</label>
</div>
<div class="gchoice gchoice_10_54_1">
<input class="gfield-choice-input" name="input_54" type="radio" value="No" id="choice_10_54_1" onchange="gformToggleRadioOther( this )">
<label for="choice_10_54_1" id="label_10_54_1" class="gform-field-label gform-field-label--type-inline">No</label>
</div>
</div>
</div>
</fieldset>
<fieldset id="field_10_55" class="gfield gfield--type-radio gfield--type-choice gfield--width-third field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible"
data-js-reload="field_10_55">
<legend class="gfield_label gform-field-label">Asthma</legend>
<div class="ginput_container ginput_container_radio">
<div class="gfield_radio" id="input_10_55">
<div class="gchoice gchoice_10_55_0">
<input class="gfield-choice-input" name="input_55" type="radio" value="Yes" id="choice_10_55_0" onchange="gformToggleRadioOther( this )">
<label for="choice_10_55_0" id="label_10_55_0" class="gform-field-label gform-field-label--type-inline">Yes</label>
</div>
<div class="gchoice gchoice_10_55_1">
<input class="gfield-choice-input" name="input_55" type="radio" value="No" id="choice_10_55_1" onchange="gformToggleRadioOther( this )">
<label for="choice_10_55_1" id="label_10_55_1" class="gform-field-label gform-field-label--type-inline">No</label>
</div>
</div>
</div>
</fieldset>
<fieldset id="field_10_56" class="gfield gfield--type-radio gfield--type-choice gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible"
data-js-reload="field_10_56">
<legend class="gfield_label gform-field-label">COPD</legend>
<div class="ginput_container ginput_container_radio">
<div class="gfield_radio" id="input_10_56">
<div class="gchoice gchoice_10_56_0">
<input class="gfield-choice-input" name="input_56" type="radio" value="Yes" id="choice_10_56_0" onchange="gformToggleRadioOther( this )">
<label for="choice_10_56_0" id="label_10_56_0" class="gform-field-label gform-field-label--type-inline">Yes</label>
</div>
<div class="gchoice gchoice_10_56_1">
<input class="gfield-choice-input" name="input_56" type="radio" value="No" id="choice_10_56_1" onchange="gformToggleRadioOther( this )">
<label for="choice_10_56_1" id="label_10_56_1" class="gform-field-label gform-field-label--type-inline">No</label>
</div>
</div>
</div>
</fieldset>
<div id="field_10_57" class="gfield gfield--type-text gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible" data-js-reload="field_10_57"><label
class="gfield_label gform-field-label" for="input_10_57">If yes, please state the year(s) when were you first diagnosed?</label>
<div class="ginput_container ginput_container_text"><input name="input_57" id="input_10_57" type="text" value="" class="large" aria-invalid="false"> </div>
</div>
<div id="field_10_58" class="gfield gfield--type-text gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible" data-js-reload="field_10_58"><label
class="gfield_label gform-field-label" for="input_10_58">Please list any medicines being taken and the amount:</label>
<div class="ginput_container ginput_container_text"><input name="input_58" id="input_10_58" type="text" value="" class="large" aria-invalid="false"> </div>
</div>
<fieldset id="field_10_59" class="gfield gfield--type-radio gfield--type-choice gfield--width-third field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible"
data-js-reload="field_10_59">
<legend class="gfield_label gform-field-label">Are you registered disabled?</legend>
<div class="ginput_container ginput_container_radio">
<div class="gfield_radio" id="input_10_59">
<div class="gchoice gchoice_10_59_0">
<input class="gfield-choice-input" name="input_59" type="radio" value="Yes" id="choice_10_59_0" onchange="gformToggleRadioOther( this )">
<label for="choice_10_59_0" id="label_10_59_0" class="gform-field-label gform-field-label--type-inline">Yes</label>
</div>
<div class="gchoice gchoice_10_59_1">
<input class="gfield-choice-input" name="input_59" type="radio" value="No" id="choice_10_59_1" onchange="gformToggleRadioOther( this )">
<label for="choice_10_59_1" id="label_10_59_1" class="gform-field-label gform-field-label--type-inline">No</label>
</div>
</div>
</div>
</fieldset>
<div id="field_10_60" class="gfield gfield--type-text gfield--width-two-thirds field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible" data-js-reload="field_10_60"><label
class="gfield_label gform-field-label" for="input_10_60">If yes, please give details:</label>
<div class="ginput_container ginput_container_text"><input name="input_60" id="input_10_60" type="text" value="" class="large" aria-invalid="false"> </div>
</div>
<fieldset id="field_10_61" class="gfield gfield--type-radio gfield--type-choice gfield--width-third field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible"
data-js-reload="field_10_61">
<legend class="gfield_label gform-field-label">Have you ever refused treatment/screening of any kind?</legend>
<div class="ginput_container ginput_container_radio">
<div class="gfield_radio" id="input_10_61">
<div class="gchoice gchoice_10_61_0">
<input class="gfield-choice-input" name="input_61" type="radio" value="Yes" id="choice_10_61_0" onchange="gformToggleRadioOther( this )">
<label for="choice_10_61_0" id="label_10_61_0" class="gform-field-label gform-field-label--type-inline">Yes</label>
</div>
<div class="gchoice gchoice_10_61_1">
<input class="gfield-choice-input" name="input_61" type="radio" value="No" id="choice_10_61_1" onchange="gformToggleRadioOther( this )">
<label for="choice_10_61_1" id="label_10_61_1" class="gform-field-label gform-field-label--type-inline">No</label>
</div>
</div>
</div>
</fieldset>
<div id="field_10_62" class="gfield gfield--type-text gfield--width-two-thirds field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible" data-js-reload="field_10_62"><label
class="gfield_label gform-field-label" for="input_10_62">If yes, please give details:</label>
<div class="ginput_container ginput_container_text"><input name="input_62" id="input_10_62" type="text" value="" class="large" aria-invalid="false"> </div>
</div>
<fieldset id="field_10_63" class="gfield gfield--type-radio gfield--type-choice gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible"
data-js-reload="field_10_63">
<legend class="gfield_label gform-field-label">Are you allergic to any medicines?</legend>
<div class="ginput_container ginput_container_radio">
<div class="gfield_radio" id="input_10_63">
<div class="gchoice gchoice_10_63_0">
<input class="gfield-choice-input" name="input_63" type="radio" value="Yes" id="choice_10_63_0" onchange="gformToggleRadioOther( this )">
<label for="choice_10_63_0" id="label_10_63_0" class="gform-field-label gform-field-label--type-inline">Yes</label>
</div>
<div class="gchoice gchoice_10_63_1">
<input class="gfield-choice-input" name="input_63" type="radio" value="No" id="choice_10_63_1" onchange="gformToggleRadioOther( this )">
<label for="choice_10_63_1" id="label_10_63_1" class="gform-field-label gform-field-label--type-inline">No</label>
</div>
</div>
</div>
</fieldset>
<div id="field_10_64" class="gfield gfield--type-text gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible" data-js-reload="field_10_64"><label
class="gfield_label gform-field-label" for="input_10_64">If so, what and when?</label>
<div class="ginput_container ginput_container_text"><input name="input_64" id="input_10_64" type="text" value="" class="large" aria-invalid="false"> </div>
</div>
<div id="field_10_65"
class="gfield gfield--type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible"
data-js-reload="field_10_65">Have you ever suffered from? (tick as appropriate)</div>
<fieldset id="field_10_66" class="gfield gfield--type-radio gfield--type-choice gfield--width-quarter field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible"
data-js-reload="field_10_66">
<legend class="gfield_label gform-field-label">Anxiety</legend>
<div class="ginput_container ginput_container_radio">
<div class="gfield_radio" id="input_10_66">
<div class="gchoice gchoice_10_66_0">
<input class="gfield-choice-input" name="input_66" type="radio" value="Yes" id="choice_10_66_0" onchange="gformToggleRadioOther( this )">
<label for="choice_10_66_0" id="label_10_66_0" class="gform-field-label gform-field-label--type-inline">Yes</label>
</div>
<div class="gchoice gchoice_10_66_1">
<input class="gfield-choice-input" name="input_66" type="radio" value="No" id="choice_10_66_1" onchange="gformToggleRadioOther( this )">
<label for="choice_10_66_1" id="label_10_66_1" class="gform-field-label gform-field-label--type-inline">No</label>
</div>
</div>
</div>
</fieldset>
<fieldset id="field_10_67" class="gfield gfield--type-radio gfield--type-choice gfield--width-quarter field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible"
data-js-reload="field_10_67">
<legend class="gfield_label gform-field-label">Depression</legend>
<div class="ginput_container ginput_container_radio">
<div class="gfield_radio" id="input_10_67">
<div class="gchoice gchoice_10_67_0">
<input class="gfield-choice-input" name="input_67" type="radio" value="Yes" id="choice_10_67_0" onchange="gformToggleRadioOther( this )">
<label for="choice_10_67_0" id="label_10_67_0" class="gform-field-label gform-field-label--type-inline">Yes</label>
</div>
<div class="gchoice gchoice_10_67_1">
<input class="gfield-choice-input" name="input_67" type="radio" value="No" id="choice_10_67_1" onchange="gformToggleRadioOther( this )">
<label for="choice_10_67_1" id="label_10_67_1" class="gform-field-label gform-field-label--type-inline">No</label>
</div>
</div>
</div>
</fieldset>
<fieldset id="field_10_68" class="gfield gfield--type-radio gfield--type-choice gfield--width-quarter field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible"
data-js-reload="field_10_68">
<legend class="gfield_label gform-field-label">OCD</legend>
<div class="ginput_container ginput_container_radio">
<div class="gfield_radio" id="input_10_68">
<div class="gchoice gchoice_10_68_0">
<input class="gfield-choice-input" name="input_68" type="radio" value="Yes" id="choice_10_68_0" onchange="gformToggleRadioOther( this )">
<label for="choice_10_68_0" id="label_10_68_0" class="gform-field-label gform-field-label--type-inline">Yes</label>
</div>
<div class="gchoice gchoice_10_68_1">
<input class="gfield-choice-input" name="input_68" type="radio" value="No" id="choice_10_68_1" onchange="gformToggleRadioOther( this )">
<label for="choice_10_68_1" id="label_10_68_1" class="gform-field-label gform-field-label--type-inline">No</label>
</div>
</div>
</div>
</fieldset>
<fieldset id="field_10_69" class="gfield gfield--type-radio gfield--type-choice gfield--width-quarter field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible"
data-js-reload="field_10_69">
<legend class="gfield_label gform-field-label">Bipolar Disorder</legend>
<div class="ginput_container ginput_container_radio">
<div class="gfield_radio" id="input_10_69">
<div class="gchoice gchoice_10_69_0">
<input class="gfield-choice-input" name="input_69" type="radio" value="Yes" id="choice_10_69_0" onchange="gformToggleRadioOther( this )">
<label for="choice_10_69_0" id="label_10_69_0" class="gform-field-label gform-field-label--type-inline">Yes</label>
</div>
<div class="gchoice gchoice_10_69_1">
<input class="gfield-choice-input" name="input_69" type="radio" value="No" id="choice_10_69_1" onchange="gformToggleRadioOther( this )">
<label for="choice_10_69_1" id="label_10_69_1" class="gform-field-label gform-field-label--type-inline">No</label>
</div>
</div>
</div>
</fieldset>
<div id="field_10_70" class="gfield gfield--type-text gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible" data-js-reload="field_10_70"><label
class="gfield_label gform-field-label" for="input_10_70">If yes to any of these, please state the year(s) when were you first diagnosed?</label>
<div class="ginput_container ginput_container_text"><input name="input_70" id="input_10_70" type="text" value="" class="large" aria-invalid="false"> </div>
</div>
<div id="field_10_71" class="gfield gfield--type-text gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible" data-js-reload="field_10_71"><label
class="gfield_label gform-field-label" for="input_10_71">Do you have any other mental health issues? (If yes please give details)</label>
<div class="ginput_container ginput_container_text"><input name="input_71" id="input_10_71" type="text" value="" class="large" aria-invalid="false"> </div>
</div>
<div id="field_10_72" class="gfield gfield--type-text gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible" data-js-reload="field_10_72"><label
class="gfield_label gform-field-label" for="input_10_72">Are you receiving or have you received any treatment or therapy? (If yes please give details of your care and when you received it)</label>
<div class="ginput_container ginput_container_text"><input name="input_72" id="input_10_72" type="text" value="" class="large" aria-invalid="false"> </div>
</div>
<div id="field_10_73"
class="gfield gfield--type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible"
data-js-reload="field_10_73">
<h5>Carers </h5>
</div>
<fieldset id="field_10_74" class="gfield gfield--type-radio gfield--type-choice gfield--width-third field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible"
data-js-reload="field_10_74">
<legend class="gfield_label gform-field-label">Do you have a carer?</legend>
<div class="ginput_container ginput_container_radio">
<div class="gfield_radio" id="input_10_74">
<div class="gchoice gchoice_10_74_0">
<input class="gfield-choice-input" name="input_74" type="radio" value="Yes" id="choice_10_74_0" onchange="gformToggleRadioOther( this )">
<label for="choice_10_74_0" id="label_10_74_0" class="gform-field-label gform-field-label--type-inline">Yes</label>
</div>
<div class="gchoice gchoice_10_74_1">
<input class="gfield-choice-input" name="input_74" type="radio" value="No" id="choice_10_74_1" onchange="gformToggleRadioOther( this )">
<label for="choice_10_74_1" id="label_10_74_1" class="gform-field-label gform-field-label--type-inline">No</label>
</div>
</div>
</div>
</fieldset>
<div id="field_10_75" class="gfield gfield--type-text gfield--width-two-thirds field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible" data-js-reload="field_10_75"><label
class="gfield_label gform-field-label" for="input_10_75">If yes please give details:</label>
<div class="ginput_container ginput_container_text"><input name="input_75" id="input_10_75" type="text" value="" class="large" aria-invalid="false"> </div>
</div>
<fieldset id="field_10_76" class="gfield gfield--type-radio gfield--type-choice gfield--width-third field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible"
data-js-reload="field_10_76">
<legend class="gfield_label gform-field-label">Are you a carer?</legend>
<div class="ginput_container ginput_container_radio">
<div class="gfield_radio" id="input_10_76">
<div class="gchoice gchoice_10_76_0">
<input class="gfield-choice-input" name="input_76" type="radio" value="Yes" id="choice_10_76_0" onchange="gformToggleRadioOther( this )">
<label for="choice_10_76_0" id="label_10_76_0" class="gform-field-label gform-field-label--type-inline">Yes</label>
</div>
<div class="gchoice gchoice_10_76_1">
<input class="gfield-choice-input" name="input_76" type="radio" value="No" id="choice_10_76_1" onchange="gformToggleRadioOther( this )">
<label for="choice_10_76_1" id="label_10_76_1" class="gform-field-label gform-field-label--type-inline">No</label>
</div>
</div>
</div>
</fieldset>
<div id="field_10_77" class="gfield gfield--type-text gfield--width-two-thirds field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible" data-js-reload="field_10_77"><label
class="gfield_label gform-field-label" for="input_10_77">If yes please give details:</label>
<div class="ginput_container ginput_container_text"><input name="input_77" id="input_10_77" type="text" value="" class="large" aria-invalid="false"> </div>
</div>
<div id="field_10_78"
class="gfield gfield--type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible"
data-js-reload="field_10_78">
<h5>Wills </h5>
</div>
<fieldset id="field_10_79" class="gfield gfield--type-radio gfield--type-choice gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible"
data-js-reload="field_10_79">
<legend class="gfield_label gform-field-label">Do you hold a Living Will?</legend>
<div class="ginput_container ginput_container_radio">
<div class="gfield_radio" id="input_10_79">
<div class="gchoice gchoice_10_79_0">
<input class="gfield-choice-input" name="input_79" type="radio" value="Yes" id="choice_10_79_0" onchange="gformToggleRadioOther( this )">
<label for="choice_10_79_0" id="label_10_79_0" class="gform-field-label gform-field-label--type-inline">Yes</label>
</div>
<div class="gchoice gchoice_10_79_1">
<input class="gfield-choice-input" name="input_79" type="radio" value="No" id="choice_10_79_1" onchange="gformToggleRadioOther( this )">
<label for="choice_10_79_1" id="label_10_79_1" class="gform-field-label gform-field-label--type-inline">No</label>
</div>
</div>
</div>
</fieldset>
<div id="field_10_80"
class="gfield gfield--type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible"
data-js-reload="field_10_80">(A Living Will is documentation regarding your personal wishes in respect of medical intervention at the time of serious illness)</div>
<div id="field_10_82"
class="gfield gfield--type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible"
data-js-reload="field_10_82">
<h5>Women </h5>
</div>
<fieldset id="field_10_83" class="gfield gfield--type-radio gfield--type-choice gfield--width-third field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible"
data-js-reload="field_10_83">
<legend class="gfield_label gform-field-label">Have you ever had a cervical smear?</legend>
<div class="ginput_container ginput_container_radio">
<div class="gfield_radio" id="input_10_83">
<div class="gchoice gchoice_10_83_0">
<input class="gfield-choice-input" name="input_83" type="radio" value="Yes" id="choice_10_83_0" onchange="gformToggleRadioOther( this )">
<label for="choice_10_83_0" id="label_10_83_0" class="gform-field-label gform-field-label--type-inline">Yes</label>
</div>
<div class="gchoice gchoice_10_83_1">
<input class="gfield-choice-input" name="input_83" type="radio" value="No" id="choice_10_83_1" onchange="gformToggleRadioOther( this )">
<label for="choice_10_83_1" id="label_10_83_1" class="gform-field-label gform-field-label--type-inline">No</label>
</div>
</div>
</div>
</fieldset>
<div id="field_10_84" class="gfield gfield--type-text gfield--width-two-thirds field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible" data-js-reload="field_10_84"><label
class="gfield_label gform-field-label" for="input_10_84">If 'yes', please state when, where and the result:</label>
<div class="ginput_container ginput_container_text"><input name="input_84" id="input_10_84" type="text" value="" class="large" placeholder="Give details and when these issues arose" aria-invalid="false"> </div>
</div>
<div id="field_10_85"
class="gfield gfield--type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible"
data-js-reload="field_10_85">
<h5>Smoking </h5>
</div>
<fieldset id="field_10_86" class="gfield gfield--type-radio gfield--type-choice gfield--width-third field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible"
data-js-reload="field_10_86">
<legend class="gfield_label gform-field-label">Do you smoke?</legend>
<div class="ginput_container ginput_container_radio">
<div class="gfield_radio" id="input_10_86">
<div class="gchoice gchoice_10_86_0">
<input class="gfield-choice-input" name="input_86" type="radio" value="Yes" id="choice_10_86_0" onchange="gformToggleRadioOther( this )">
<label for="choice_10_86_0" id="label_10_86_0" class="gform-field-label gform-field-label--type-inline">Yes</label>
</div>
<div class="gchoice gchoice_10_86_1">
<input class="gfield-choice-input" name="input_86" type="radio" value="No" id="choice_10_86_1" onchange="gformToggleRadioOther( this )">
<label for="choice_10_86_1" id="label_10_86_1" class="gform-field-label gform-field-label--type-inline">No</label>
</div>
</div>
</div>
</fieldset>
<fieldset id="field_10_87" class="gfield gfield--type-radio gfield--type-choice gfield--width-third field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible"
data-js-reload="field_10_87">
<legend class="gfield_label gform-field-label">If 'No', have you ever smoked?</legend>
<div class="ginput_container ginput_container_radio">
<div class="gfield_radio" id="input_10_87">
<div class="gchoice gchoice_10_87_0">
<input class="gfield-choice-input" name="input_87" type="radio" value="Yes" id="choice_10_87_0" onchange="gformToggleRadioOther( this )">
<label for="choice_10_87_0" id="label_10_87_0" class="gform-field-label gform-field-label--type-inline">Yes</label>
</div>
<div class="gchoice gchoice_10_87_1">
<input class="gfield-choice-input" name="input_87" type="radio" value="No" id="choice_10_87_1" onchange="gformToggleRadioOther( this )">
<label for="choice_10_87_1" id="label_10_87_1" class="gform-field-label gform-field-label--type-inline">No</label>
</div>
</div>
</div>
</fieldset>
<fieldset id="field_10_88" class="gfield gfield--type-radio gfield--type-choice gfield--width-third field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible"
data-js-reload="field_10_88">
<legend class="gfield_label gform-field-label">Would you like advice on giving up smoking?</legend>
<div class="ginput_container ginput_container_radio">
<div class="gfield_radio" id="input_10_88">
<div class="gchoice gchoice_10_88_0">
<input class="gfield-choice-input" name="input_88" type="radio" value="Yes" id="choice_10_88_0" onchange="gformToggleRadioOther( this )">
<label for="choice_10_88_0" id="label_10_88_0" class="gform-field-label gform-field-label--type-inline">Yes</label>
</div>
<div class="gchoice gchoice_10_88_1">
<input class="gfield-choice-input" name="input_88" type="radio" value="No" id="choice_10_88_1" onchange="gformToggleRadioOther( this )">
<label for="choice_10_88_1" id="label_10_88_1" class="gform-field-label gform-field-label--type-inline">No</label>
</div>
</div>
</div>
</fieldset>
<div id="field_10_89" class="gfield gfield--type-text gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible" data-js-reload="field_10_89"><label
class="gfield_label gform-field-label" for="input_10_89">If you do currently smoke, how many cigarettes or ounces of tobacco do you smoke per week?</label>
<div class="ginput_container ginput_container_text"><input name="input_89" id="input_10_89" type="text" value="" class="large" aria-invalid="false"> </div>
</div>
<div id="field_10_90"
class="gfield gfield--type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible"
data-js-reload="field_10_90">
<h5> Alcohol </h5> 1 drink = 1/2 pint of beer or 1 glass of wine or 1 single spirits
</div>
<div id="field_10_91" class="gfield gfield--type-select gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible" data-js-reload="field_10_91"><label
class="gfield_label gform-field-label" for="input_10_91">MEN: How often do you have EIGHT or more drinks on one occasion?</label>
<div class="ginput_container ginput_container_select"><select name="input_91" id="input_10_91" class="large gfield_select" aria-invalid="false">
<option value="Never">Never</option>
<option value="Less than monthly">Less than monthly</option>
<option value="Monthly">Monthly</option>
<option value="Weekly">Weekly</option>
<option value="Daily">Daily</option>
</select></div>
</div>
<div id="field_10_92" class="gfield gfield--type-select gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible" data-js-reload="field_10_92"><label
class="gfield_label gform-field-label" for="input_10_92">WOMEN: How often do you have SIX or more drinks on one occasion?</label>
<div class="ginput_container ginput_container_select"><select name="input_92" id="input_10_92" class="large gfield_select" aria-invalid="false">
<option value="Never">Never</option>
<option value="Less than monthly">Less than monthly</option>
<option value="Monthly">Monthly</option>
<option value="Weekly">Weekly</option>
<option value="Daily">Daily</option>
</select></div>
</div>
<div id="field_10_93" class="gfield gfield--type-select gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible" data-js-reload="field_10_93"><label
class="gfield_label gform-field-label" for="input_10_93">How often during the last year have you been unable to remember what happened the night before because you had been drinking?</label>
<div class="ginput_container ginput_container_select"><select name="input_93" id="input_10_93" class="large gfield_select" aria-invalid="false">
<option value="Never">Never</option>
<option value="Less than monthly">Less than monthly</option>
<option value="Monthly">Monthly</option>
<option value="Weekly">Weekly</option>
<option value="Daily">Daily</option>
</select></div>
</div>
<div id="field_10_94" class="gfield gfield--type-select gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible" data-js-reload="field_10_94"><label
class="gfield_label gform-field-label" for="input_10_94">How often during the last year have you failed to do what was normally expected of you because of drinking?</label>
<div class="ginput_container ginput_container_select"><select name="input_94" id="input_10_94" class="large gfield_select" aria-invalid="false">
<option value="Never">Never</option>
<option value="Less than monthly">Less than monthly</option>
<option value="Monthly">Monthly</option>
<option value="Weekly">Weekly</option>
<option value="Daily">Daily</option>
</select></div>
</div>
<div id="field_10_95" class="gfield gfield--type-select gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible" data-js-reload="field_10_95"><label
class="gfield_label gform-field-label" for="input_10_95">In the last year has a relative or friend, or a doctor or other health worker been concerned about your drinking or suggested you cut down?</label>
<div class="ginput_container ginput_container_select"><select name="input_95" id="input_10_95" class="large gfield_select" aria-invalid="false">
<option value="No">No</option>
<option value="Yes, on one occasion">Yes, on one occasion</option>
<option value="Yes, more than once">Yes, more than once</option>
</select></div>
</div>
<div id="field_10_96"
class="gfield gfield--type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible"
data-js-reload="field_10_96">
<h5>Family History </h5>
</div>
<div id="field_10_98" class="gfield gfield--type-text gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible" data-js-reload="field_10_98"><label
class="gfield_label gform-field-label" for="input_10_98">Please state any serious illness, in particular cancer, heart disease, stroke, high blood pressure, diabetes or any inherited disease. Please state your relationship to the individual
and in the case of cancer, the type of cancer.</label>
<div class="ginput_container ginput_container_text"><input name="input_98" id="input_10_98" type="text" value="" class="large" aria-invalid="false"> </div>
</div>
<div id="field_10_97"
class="gfield gfield--type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible"
data-js-reload="field_10_97">
<h5>Next of Kin </h5>
</div>
<div id="field_10_99" class="gfield gfield--type-text gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible" data-js-reload="field_10_99"><label
class="gfield_label gform-field-label" for="input_10_99">Please give name, address, telephone number and relationship of next of kin:</label>
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<div id="field_10_100"
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<h5>Contacting you </h5>
</div>
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<div class="ginput_container ginput_container_text"><input name="input_102" id="input_10_102" type="text" value="" class="large" placeholder="Never" aria-invalid="false"> </div>
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<div id="field_10_103"
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<h5>For patients aged 65 and over or those with a chronic disease (e.g. asthma or diabetes) </h5>
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<legend class="gfield_label gform-field-label gfield_label_before_complex">Untitled<span class="gfield_required"><span class="gfield_required gfield_required_text">(Required)</span></span></legend>
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<label for="choice_10_104_1" id="label_10_104_1" class="gform-field-label gform-field-label--type-inline">I agree that I may be contacted from time to time, via email and/or SMS, with practice news, advice about my health and/or
appointment reminders.</label>
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</form>POST /
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<div class="gform-body gform_body">
<div id="gform_fields_12" class="gform_fields top_label form_sublabel_below description_below validation_below">
<div id="field_12_1" class="gfield gfield--type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible"
data-js-reload="field_12_1">
<div class="frm-title">Registering with a GP surgery outside the area you live?</div>
<div class="frm-desc">You do not need to register with a GP surgery in the area you live.</div>
<div class="frm-desc">You can register with a surgery that's more convenient, for example closer to your work or your children's school..</div>
<div class="frm-desc">The GP surgery can refuse registration for reasons such as they are not taking new patients or it's too far away from your home and you need home visits.</div>
<div class="fr-name"> Your details</div>
</div>
<div id="field_12_8" class="gfield gfield--type-select gfield--width-third field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible" data-js-reload="field_12_8"><label
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<option value="Mr.">Mr.</option>
<option value="Mrs.">Mrs.</option>
<option value="Miss.">Miss.</option>
<option value="Ms.">Ms.</option>
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<label class="gfield_label gform-field-label" for="input_12_5">First name:<span class="gfield_required"><span class="gfield_required gfield_required_text">(Required)</span></span></label>
<div class="ginput_container ginput_container_text"><input name="input_5" id="input_12_5" type="text" value="" class="large" aria-required="true" aria-invalid="false"> </div>
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<label class="gfield_label gform-field-label" for="input_12_7">Last name(s):<span class="gfield_required"><span class="gfield_required gfield_required_text">(Required)</span></span></label>
<div class="ginput_container ginput_container_text"><input name="input_7" id="input_12_7" type="text" value="" class="large" aria-required="true" aria-invalid="false"> </div>
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<div class="ginput_container ginput_container_date">
<input name="input_9" id="input_12_9" type="text" value="" class="datepicker gform-datepicker dmy datepicker_with_icon gdatepicker_with_icon hasDatepicker initialized" placeholder="dd/mm/yyyy" aria-describedby="input_12_9_date_format"
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<div class="ginput_container ginput_container_email">
<input name="input_29" id="input_12_29" type="email" value="" class="large" aria-required="true" aria-invalid="false">
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<div id="field_12_15"
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<div class="md-title">Reason for registering with our practice in London</div>
</div>
<div id="field_12_35" class="gfield gfield--type-select gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible"
data-js-reload="field_12_35"><label class="gfield_label gform-field-label" for="input_12_35">Do any of the following reasons for London GP Registration apply?<span class="gfield_required"><span
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<option value="I live in London">I live in London</option>
<option value="I work in London">I work in London</option>
<option value="I attend a University, College or educational establishment in London">I attend a University, College or educational establishment in London</option>
<option value="I visit London at least once a week">I visit London at least once a week</option>
<option value="I am having difficulty registering with a GP in my area">I am having difficulty registering with a GP in my area</option>
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<div id="field_12_36"
class="gfield gfield--type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible"
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<div class="md-title red">Terms of Registering with GP far away from home. </div>
<div class="frm-desc">The surgery will decide if they can accept you as a regular patient or accept you without home visits.</div>
<div class="frm-desc">Because of the distance to your home, the GP surgery <strong><u>might not be able to offer home visits.</u></strong></div>
<div class="frm-desc">If you are not well enough to go to the GP surgery, other arrangements might be made.</div>
<div class="frm-desc">Registering with a practice further away from home can affect decisions about
<a value="https://www.nhs.uk/nhs-services/hospitals/referrals-for-specialist-care/" label="" type="url" target="_blank" href="https://www.nhs.uk/nhs-services/hospitals/referrals-for-specialist-care/" data-runtime-url="https://www.nhs.uk/nhs-services/hospitals/referrals-for-specialist-care/" id="1902494907" duda_id="1902494907" no_space_e="true" raw_url="https://www.nhs.uk/nhs-services/hospitals/referrals-for-specialist-care/">referrals for hospital tests and treatment</a>,
or
<a value="https://www.gov.uk/government/publications/the-nhs-choice-framework" label="" type="url" target="_blank" href="https://www.gov.uk/government/publications/the-nhs-choice-framework" data-runtime-url="https://www.gov.uk/government/publications/the-nhs-choice-framework" id="1690773487" duda_id="1690773487" no_space_e="true" raw_url="https://www.gov.uk/government/publications/the-nhs-choice-framework">access to community health services</a>
</div>
<div class="frm-desc">Additionally the offer of
<a value="https://www.nhs.uk/conditions/cervical-screening/" label="" type="url" target="_blank" href="https://www.nhs.uk/conditions/cervical-screening/" data-runtime-url="https://www.nhs.uk/conditions/cervical-screening/" id="1902705097" duda_id="1902705097" raw_url="https://www.nhs.uk/conditions/cervical-screening/">Cancer Screen Services</a>
and practice based <span style="text-decoration:underline" id="1625922113" duda_id="1625922113">Blood Tests and Investigations</span> maybe a long distance for you to travel</div>
<div class="md-title red underline">Do you accept the Terms of Registering with a GP far away from home? </div>
</div>
<div id="field_12_37" class="gfield gfield--type-select gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible"
data-js-reload="field_12_37"><label class="gfield_label gform-field-label" for="input_12_37">Do you accept the Terms of Registering with a GP far away from home?<span class="gfield_required"><span
class="gfield_required gfield_required_text">(Required)</span></span></label>
<div class="ginput_container ginput_container_select"><select name="input_37" id="input_12_37" class="large gfield_select" aria-required="true" aria-invalid="false">
<option value="Yes">Yes</option>
<option value="No">No</option>
<option value="I need more information, please call me">I need more information, please call me</option>
</select></div>
</div>
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</div>
<div class="gform_footer top_label"> <input type="submit" id="gform_submit_button_12" class="gform_button button" value="Send"
onclick="if(window["gf_submitting_12"]){return false;} if( !jQuery("#gform_12")[0].checkValidity || jQuery("#gform_12")[0].checkValidity()){window["gf_submitting_12"]=true;} "
onkeypress="if( event.keyCode == 13 ){ if(window["gf_submitting_12"]){return false;} if( !jQuery("#gform_12")[0].checkValidity || jQuery("#gform_12")[0].checkValidity()){window["gf_submitting_12"]=true;} jQuery("#gform_12").trigger("submit",[true]); }">
<input type="hidden" class="gform_hidden" name="is_submit_12" value="1">
<input type="hidden" class="gform_hidden" name="gform_submit" value="12">
<input type="hidden" class="gform_hidden" name="gform_unique_id" value="">
<input type="hidden" class="gform_hidden" name="state_12" value="WyJbXSIsIjIyZDg5ZTVjZWRhYTEzY2EyMjdhNzkzNTllOWFkYTUxIl0=">
<input type="hidden" class="gform_hidden" name="gform_target_page_number_12" id="gform_target_page_number_12" value="0">
<input type="hidden" class="gform_hidden" name="gform_source_page_number_12" id="gform_source_page_number_12" value="1">
<input type="hidden" name="gform_field_values" value="">
</div>
</form>POST /
<form method="post" enctype="multipart/form-data" id="gform_15" action="/" data-formid="15" novalidate="">
<div class="gform-body gform_body">
<div id="gform_fields_15" class="gform_fields top_label form_sublabel_below description_below validation_below">
<div id="field_15_1" class="gfield gfield--type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible"
data-js-reload="field_15_1">
<div class="frm-title">Repeat Prescription Request Form</div>
</div>
<div id="field_15_3"
class="gfield gfield--type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible"
data-js-reload="field_15_3">
<h5> Patient 1 details </h5>
</div>
<div id="field_15_4" class="gfield gfield--type-text gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible" data-js-reload="field_15_4">
<label class="gfield_label gform-field-label" for="input_15_4">Full name:<span class="gfield_required"><span class="gfield_required gfield_required_text">(Required)</span></span></label>
<div class="ginput_container ginput_container_text"><input name="input_4" id="input_15_4" type="text" value="" class="large" aria-required="true" aria-invalid="false"> </div>
</div>
<div id="field_15_5"
class="gfield gfield--type-date gfield--input-type-datepicker gfield--datepicker-default-icon gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible"
data-js-reload="field_15_5"><label class="gfield_label gform-field-label" for="input_15_5">Date of birth:<span class="gfield_required"><span class="gfield_required gfield_required_text">(Required)</span></span></label>
<div class="ginput_container ginput_container_date">
<input name="input_5" id="input_15_5" type="text" value="" class="datepicker gform-datepicker dmy datepicker_with_icon gdatepicker_with_icon hasDatepicker initialized" placeholder="dd/mm/yyyy" aria-describedby="input_15_5_date_format"
aria-invalid="false" aria-required="true"><img class="ui-datepicker-trigger" src="https://nhsgp.net/wp-content/plugins/gravityforms/images/datepicker/datepicker.svg" alt="Select date" title="Select date">
<span id="input_15_5_date_format" class="screen-reader-text">DD slash MM slash YYYY</span>
</div>
<input type="hidden" id="gforms_calendar_icon_input_15_5" class="gform_hidden" value="https://nhsgp.net/wp-content/plugins/gravityforms/images/datepicker/datepicker.svg">
</div>
<div id="field_15_6" class="gfield gfield--type-email gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible" data-js-reload="field_15_6"><label
class="gfield_label gform-field-label" for="input_15_6">Email:</label>
<div class="ginput_container ginput_container_email">
<input name="input_6" id="input_15_6" type="email" value="" class="large" aria-invalid="false">
</div>
</div>
<div id="field_15_7" class="gfield gfield--type-phone gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible" data-js-reload="field_15_7">
<label class="gfield_label gform-field-label" for="input_15_7">Daytime tel:<span class="gfield_required"><span class="gfield_required gfield_required_text">(Required)</span></span></label>
<div class="ginput_container ginput_container_phone"><input name="input_7" id="input_15_7" type="tel" value="" class="large" aria-required="true" aria-invalid="false"></div>
</div>
<div id="field_15_8" class="gfield gfield--type-text gfield--width-third gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible" data-js-reload="field_15_8">
<label class="gfield_label gform-field-label" for="input_15_8">Patient ID:<span class="gfield_required"><span class="gfield_required gfield_required_text">(Required)</span></span></label>
<div class="ginput_container ginput_container_text"><input name="input_8" id="input_15_8" type="text" value="" class="large" aria-required="true" aria-invalid="false"> </div>
</div>
<div id="field_15_9" class="gfield gfield--type-select gfield--width-third field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible" data-js-reload="field_15_9"><label
class="gfield_label gform-field-label" for="input_15_9">Your Doctor:</label>
<div class="ginput_container ginput_container_select"><select name="input_9" id="input_15_9" class="large gfield_select" aria-invalid="false">
<option value="Dr Sandra Foreman">Dr Sandra Foreman</option>
<option value="Dr Billy Neighbour">Dr Billy Neighbour</option>
<option value="Prof Paul Lum">Prof Paul Lum</option>
</select></div>
</div>
<div id="field_15_10" class="gfield gfield--type-select gfield--width-third field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible" data-js-reload="field_15_10"><label
class="gfield_label gform-field-label" for="input_15_10">Collect from:</label>
<div class="ginput_container ginput_container_select"><select name="input_10" id="input_15_10" class="large gfield_select" aria-invalid="false">
<option value="The Surgery">The Surgery</option>
<option value="Bierley Pharmacy">Bierley Pharmacy</option>
<option value="Lloyds Pharmacy - Rooley lane">Lloyds Pharmacy - Rooley lane</option>
<option value="Boots">Boots</option>
<option value="Lloyds Cults">Lloyds Cults</option>
<option value="Rowland Cults">Rowland Cults</option>
<option value="Woods, Peterculter">Woods, Peterculter</option>
<option value="Jones Pharmacy">Jones Pharmacy</option>
</select></div>
</div>
<div id="field_15_11"
class="gfield gfield--type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible"
data-js-reload="field_15_11">You may request up to twenty separate items. Enter each drug and strength on your prescription. Untick the 'Required' box if you do not require the item this time. Please note that items will only be dispensed if
they are included on your repeat prescription and a medication review is not pending</div>
<div id="field_15_12" class="gfield gfield--type-text gfield--width-third field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible" data-js-reload="field_15_12"><label
class="gfield_label gform-field-label" for="input_15_12">Drug</label>
<div class="ginput_container ginput_container_text"><input name="input_12" id="input_15_12" type="text" value="" class="large" placeholder="Drug" aria-invalid="false"> </div>
</div>
<div id="field_15_13" class="gfield gfield--type-text gfield--width-third field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible" data-js-reload="field_15_13"><label
class="gfield_label gform-field-label" for="input_15_13">Untitled</label>
<div class="ginput_container ginput_container_text"><input name="input_13" id="input_15_13" type="text" value="" class="large" placeholder="Quantity and/or strength" aria-invalid="false"> </div>
</div>
<fieldset id="field_15_14" class="gfield gfield--type-checkbox gfield--type-choice gfield--width-third field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible"
data-js-reload="field_15_14">
<legend class="gfield_label gform-field-label gfield_label_before_complex">Untitled</legend>
<div class="ginput_container ginput_container_checkbox">
<div class="gfield_checkbox" id="input_15_14">
<div class="gchoice gchoice_15_14_1">
<input class="gfield-choice-input" name="input_14.1" type="checkbox" value="Required" id="choice_15_14_1">
<label for="choice_15_14_1" id="label_15_14_1" class="gform-field-label gform-field-label--type-inline">Required</label>
</div>
</div>
</div>
</fieldset>
<div id="field_15_15" class="gfield gfield--type-text gfield--width-third field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible" data-js-reload="field_15_15"><label
class="gfield_label gform-field-label" for="input_15_15">Drug</label>
<div class="ginput_container ginput_container_text"><input name="input_15" id="input_15_15" type="text" value="" class="large" placeholder="Drug" aria-invalid="false"> </div>
</div>
<div id="field_15_16" class="gfield gfield--type-text gfield--width-third field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible" data-js-reload="field_15_16"><label
class="gfield_label gform-field-label" for="input_15_16">Untitled</label>
<div class="ginput_container ginput_container_text"><input name="input_16" id="input_15_16" type="text" value="" class="large" placeholder="Quantity and/or strength" aria-invalid="false"> </div>
</div>
<fieldset id="field_15_17" class="gfield gfield--type-checkbox gfield--type-choice gfield--width-third field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible"
data-js-reload="field_15_17">
<legend class="gfield_label gform-field-label gfield_label_before_complex">Untitled</legend>
<div class="ginput_container ginput_container_checkbox">
<div class="gfield_checkbox" id="input_15_17">
<div class="gchoice gchoice_15_17_1">
<input class="gfield-choice-input" name="input_17.1" type="checkbox" value="Required" id="choice_15_17_1">
<label for="choice_15_17_1" id="label_15_17_1" class="gform-field-label gform-field-label--type-inline">Required</label>
</div>
</div>
</div>
</fieldset>
<div id="field_15_24" class="gfield gfield--type-text gfield--width-third field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible" data-js-reload="field_15_24"><label
class="gfield_label gform-field-label" for="input_15_24">Drug</label>
<div class="ginput_container ginput_container_text"><input name="input_24" id="input_15_24" type="text" value="" class="large" placeholder="Drug" aria-invalid="false"> </div>
</div>
<div id="field_15_25" class="gfield gfield--type-text gfield--width-third field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible" data-js-reload="field_15_25"><label
class="gfield_label gform-field-label" for="input_15_25">Untitled</label>
<div class="ginput_container ginput_container_text"><input name="input_25" id="input_15_25" type="text" value="" class="large" placeholder="Quantity and/or strength" aria-invalid="false"> </div>
</div>
<fieldset id="field_15_26" class="gfield gfield--type-checkbox gfield--type-choice gfield--width-third field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible"
data-js-reload="field_15_26">
<legend class="gfield_label gform-field-label gfield_label_before_complex">Untitled</legend>
<div class="ginput_container ginput_container_checkbox">
<div class="gfield_checkbox" id="input_15_26">
<div class="gchoice gchoice_15_26_1">
<input class="gfield-choice-input" name="input_26.1" type="checkbox" value="Required" id="choice_15_26_1">
<label for="choice_15_26_1" id="label_15_26_1" class="gform-field-label gform-field-label--type-inline">Required</label>
</div>
</div>
</div>
</fieldset>
<div id="field_15_20" class="gfield gfield--type-text gfield--width-third field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible" data-js-reload="field_15_20"><label
class="gfield_label gform-field-label" for="input_15_20">Drug</label>
<div class="ginput_container ginput_container_text"><input name="input_20" id="input_15_20" type="text" value="" class="large" placeholder="Drug" aria-invalid="false"> </div>
</div>
<div id="field_15_34" class="gfield gfield--type-text gfield--width-third field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible" data-js-reload="field_15_34"><label
class="gfield_label gform-field-label" for="input_15_34">Untitled</label>
<div class="ginput_container ginput_container_text"><input name="input_34" id="input_15_34" type="text" value="" class="large" placeholder="Quantity and/or strength" aria-invalid="false"> </div>
</div>
<fieldset id="field_15_36" class="gfield gfield--type-checkbox gfield--type-choice gfield--width-third field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible"
data-js-reload="field_15_36">
<legend class="gfield_label gform-field-label gfield_label_before_complex">Untitled</legend>
<div class="ginput_container ginput_container_checkbox">
<div class="gfield_checkbox" id="input_15_36">
<div class="gchoice gchoice_15_36_1">
<input class="gfield-choice-input" name="input_36.1" type="checkbox" value="Required" id="choice_15_36_1">
<label for="choice_15_36_1" id="label_15_36_1" class="gform-field-label gform-field-label--type-inline">Required</label>
</div>
</div>
</div>
</fieldset>
<div id="field_15_19" class="gfield gfield--type-text gfield--width-third field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible" data-js-reload="field_15_19"><label
class="gfield_label gform-field-label" for="input_15_19">Drug</label>
<div class="ginput_container ginput_container_text"><input name="input_19" id="input_15_19" type="text" value="" class="large" placeholder="Drug" aria-invalid="false"> </div>
</div>
<div id="field_15_33" class="gfield gfield--type-text gfield--width-third field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible" data-js-reload="field_15_33"><label
class="gfield_label gform-field-label" for="input_15_33">Untitled</label>
<div class="ginput_container ginput_container_text"><input name="input_33" id="input_15_33" type="text" value="" class="large" placeholder="Quantity and/or strength" aria-invalid="false"> </div>
</div>
<fieldset id="field_15_35" class="gfield gfield--type-checkbox gfield--type-choice gfield--width-third field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible"
data-js-reload="field_15_35">
<legend class="gfield_label gform-field-label gfield_label_before_complex">Untitled</legend>
<div class="ginput_container ginput_container_checkbox">
<div class="gfield_checkbox" id="input_15_35">
<div class="gchoice gchoice_15_35_1">
<input class="gfield-choice-input" name="input_35.1" type="checkbox" value="Required" id="choice_15_35_1">
<label for="choice_15_35_1" id="label_15_35_1" class="gform-field-label gform-field-label--type-inline">Required</label>
</div>
</div>
</div>
</fieldset>
<div id="field_15_21" class="gfield gfield--type-text gfield--width-third field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible" data-js-reload="field_15_21"><label
class="gfield_label gform-field-label" for="input_15_21">Drug</label>
<div class="ginput_container ginput_container_text"><input name="input_21" id="input_15_21" type="text" value="" class="large" placeholder="Drug" aria-invalid="false"> </div>
</div>
<div id="field_15_32" class="gfield gfield--type-text gfield--width-third field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible" data-js-reload="field_15_32"><label
class="gfield_label gform-field-label" for="input_15_32">Untitled</label>
<div class="ginput_container ginput_container_text"><input name="input_32" id="input_15_32" type="text" value="" class="large" placeholder="Quantity and/or strength" aria-invalid="false"> </div>
</div>
<fieldset id="field_15_27" class="gfield gfield--type-checkbox gfield--type-choice gfield--width-third field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible"
data-js-reload="field_15_27">
<legend class="gfield_label gform-field-label gfield_label_before_complex">Untitled</legend>
<div class="ginput_container ginput_container_checkbox">
<div class="gfield_checkbox" id="input_15_27">
<div class="gchoice gchoice_15_27_1">
<input class="gfield-choice-input" name="input_27.1" type="checkbox" value="Required" id="choice_15_27_1">
<label for="choice_15_27_1" id="label_15_27_1" class="gform-field-label gform-field-label--type-inline">Required</label>
</div>
</div>
</div>
</fieldset>
<div id="field_15_23" class="gfield gfield--type-text gfield--width-third field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible" data-js-reload="field_15_23"><label
class="gfield_label gform-field-label" for="input_15_23">Drug</label>
<div class="ginput_container ginput_container_text"><input name="input_23" id="input_15_23" type="text" value="" class="large" placeholder="Drug" aria-invalid="false"> </div>
</div>
<div id="field_15_30" class="gfield gfield--type-text gfield--width-third field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible" data-js-reload="field_15_30"><label
class="gfield_label gform-field-label" for="input_15_30">Untitled</label>
<div class="ginput_container ginput_container_text"><input name="input_30" id="input_15_30" type="text" value="" class="large" placeholder="Quantity and/or strength" aria-invalid="false"> </div>
</div>
<fieldset id="field_15_28" class="gfield gfield--type-checkbox gfield--type-choice gfield--width-third field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible"
data-js-reload="field_15_28">
<legend class="gfield_label gform-field-label gfield_label_before_complex">Untitled</legend>
<div class="ginput_container ginput_container_checkbox">
<div class="gfield_checkbox" id="input_15_28">
<div class="gchoice gchoice_15_28_1">
<input class="gfield-choice-input" name="input_28.1" type="checkbox" value="Required" id="choice_15_28_1">
<label for="choice_15_28_1" id="label_15_28_1" class="gform-field-label gform-field-label--type-inline">Required</label>
</div>
</div>
</div>
</fieldset>
<div id="field_15_22" class="gfield gfield--type-text gfield--width-third field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible" data-js-reload="field_15_22"><label
class="gfield_label gform-field-label" for="input_15_22">Drug</label>
<div class="ginput_container ginput_container_text"><input name="input_22" id="input_15_22" type="text" value="" class="large" placeholder="Drug" aria-invalid="false"> </div>
</div>
<div id="field_15_31" class="gfield gfield--type-text gfield--width-third field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible" data-js-reload="field_15_31"><label
class="gfield_label gform-field-label" for="input_15_31">Untitled</label>
<div class="ginput_container ginput_container_text"><input name="input_31" id="input_15_31" type="text" value="" class="large" placeholder="Quantity and/or strength" aria-invalid="false"> </div>
</div>
<fieldset id="field_15_29" class="gfield gfield--type-checkbox gfield--type-choice gfield--width-third field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible"
data-js-reload="field_15_29">
<legend class="gfield_label gform-field-label gfield_label_before_complex">Untitled</legend>
<div class="ginput_container ginput_container_checkbox">
<div class="gfield_checkbox" id="input_15_29">
<div class="gchoice gchoice_15_29_1">
<input class="gfield-choice-input" name="input_29.1" type="checkbox" value="Required" id="choice_15_29_1">
<label for="choice_15_29_1" id="label_15_29_1" class="gform-field-label gform-field-label--type-inline">Required</label>
</div>
</div>
</div>
</fieldset>
<div id="field_15_18" class="gfield gfield--type-text gfield--width-third field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible" data-js-reload="field_15_18"><label
class="gfield_label gform-field-label" for="input_15_18">Drug</label>
<div class="ginput_container ginput_container_text"><input name="input_18" id="input_15_18" type="text" value="" class="large" placeholder="Drug" aria-invalid="false"> </div>
</div>
<div id="field_15_40" class="gfield gfield--type-text gfield--width-third field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible" data-js-reload="field_15_40"><label
class="gfield_label gform-field-label" for="input_15_40">Untitled</label>
<div class="ginput_container ginput_container_text"><input name="input_40" id="input_15_40" type="text" value="" class="large" placeholder="Quantity and/or strength" aria-invalid="false"> </div>
</div>
<fieldset id="field_15_41" class="gfield gfield--type-checkbox gfield--type-choice gfield--width-third field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible"
data-js-reload="field_15_41">
<legend class="gfield_label gform-field-label gfield_label_before_complex">Untitled</legend>
<div class="ginput_container ginput_container_checkbox">
<div class="gfield_checkbox" id="input_15_41">
<div class="gchoice gchoice_15_41_1">
<input class="gfield-choice-input" name="input_41.1" type="checkbox" value="Required" id="choice_15_41_1">
<label for="choice_15_41_1" id="label_15_41_1" class="gform-field-label gform-field-label--type-inline">Required</label>
</div>
</div>
</div>
</fieldset>
<div id="field_15_39" class="gfield gfield--type-text gfield--width-third field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible" data-js-reload="field_15_39"><label
class="gfield_label gform-field-label" for="input_15_39">Drug</label>
<div class="ginput_container ginput_container_text"><input name="input_39" id="input_15_39" type="text" value="" class="large" placeholder="Drug" aria-invalid="false"> </div>
</div>
<div id="field_15_45" class="gfield gfield--type-text gfield--width-third field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible" data-js-reload="field_15_45"><label
class="gfield_label gform-field-label" for="input_15_45">Untitled</label>
<div class="ginput_container ginput_container_text"><input name="input_45" id="input_15_45" type="text" value="" class="large" placeholder="Quantity and/or strength" aria-invalid="false"> </div>
</div>
<fieldset id="field_15_42" class="gfield gfield--type-checkbox gfield--type-choice gfield--width-third field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible"
data-js-reload="field_15_42">
<legend class="gfield_label gform-field-label gfield_label_before_complex">Untitled</legend>
<div class="ginput_container ginput_container_checkbox">
<div class="gfield_checkbox" id="input_15_42">
<div class="gchoice gchoice_15_42_1">
<input class="gfield-choice-input" name="input_42.1" type="checkbox" value="Required" id="choice_15_42_1">
<label for="choice_15_42_1" id="label_15_42_1" class="gform-field-label gform-field-label--type-inline">Required</label>
</div>
</div>
</div>
</fieldset>
<div id="field_15_38" class="gfield gfield--type-text gfield--width-third field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible" data-js-reload="field_15_38"><label
class="gfield_label gform-field-label" for="input_15_38">Drug</label>
<div class="ginput_container ginput_container_text"><input name="input_38" id="input_15_38" type="text" value="" class="large" placeholder="Drug" aria-invalid="false"> </div>
</div>
<div id="field_15_46" class="gfield gfield--type-text gfield--width-third field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible" data-js-reload="field_15_46"><label
class="gfield_label gform-field-label" for="input_15_46">Untitled</label>
<div class="ginput_container ginput_container_text"><input name="input_46" id="input_15_46" type="text" value="" class="large" placeholder="Quantity and/or strength" aria-invalid="false"> </div>
</div>
<fieldset id="field_15_43" class="gfield gfield--type-checkbox gfield--type-choice gfield--width-third field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible"
data-js-reload="field_15_43">
<legend class="gfield_label gform-field-label gfield_label_before_complex">Untitled</legend>
<div class="ginput_container ginput_container_checkbox">
<div class="gfield_checkbox" id="input_15_43">
<div class="gchoice gchoice_15_43_1">
<input class="gfield-choice-input" name="input_43.1" type="checkbox" value="Required" id="choice_15_43_1">
<label for="choice_15_43_1" id="label_15_43_1" class="gform-field-label gform-field-label--type-inline">Required</label>
</div>
</div>
</div>
</fieldset>
<div id="field_15_37" class="gfield gfield--type-text gfield--width-third field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible" data-js-reload="field_15_37"><label
class="gfield_label gform-field-label" for="input_15_37">Drug</label>
<div class="ginput_container ginput_container_text"><input name="input_37" id="input_15_37" type="text" value="" class="large" placeholder="Drug" aria-invalid="false"> </div>
</div>
<div id="field_15_47" class="gfield gfield--type-text gfield--width-third field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible" data-js-reload="field_15_47"><label
class="gfield_label gform-field-label" for="input_15_47">Untitled</label>
<div class="ginput_container ginput_container_text"><input name="input_47" id="input_15_47" type="text" value="" class="large" placeholder="Quantity and/or strength" aria-invalid="false"> </div>
</div>
<fieldset id="field_15_44" class="gfield gfield--type-checkbox gfield--type-choice gfield--width-third field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible"
data-js-reload="field_15_44">
<legend class="gfield_label gform-field-label gfield_label_before_complex">Untitled</legend>
<div class="ginput_container ginput_container_checkbox">
<div class="gfield_checkbox" id="input_15_44">
<div class="gchoice gchoice_15_44_1">
<input class="gfield-choice-input" name="input_44.1" type="checkbox" value="Required" id="choice_15_44_1">
<label for="choice_15_44_1" id="label_15_44_1" class="gform-field-label gform-field-label--type-inline">Required</label>
</div>
</div>
</div>
</fieldset>
<div id="field_15_48" class="gfield gfield--type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible"
data-js-reload="field_15_48">
<h5<comments <="" h5=""></h5<comments>
</div>
<div id="field_15_49" class="gfield gfield--type-text gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible" data-js-reload="field_15_49"><label
class="gfield_label gform-field-label" for="input_15_49">Please do not include medical problems here - these should be discussed with your doctor</label>
<div class="ginput_container ginput_container_text"><input name="input_49" id="input_15_49" type="text" value="" class="large" aria-invalid="false"> </div>
</div>
</div>
</div>
<div class="gform_footer top_label"> <input type="submit" id="gform_submit_button_15" class="gform_button button" value="Send request for Patient 1"
onclick="if(window["gf_submitting_15"]){return false;} if( !jQuery("#gform_15")[0].checkValidity || jQuery("#gform_15")[0].checkValidity()){window["gf_submitting_15"]=true;} "
onkeypress="if( event.keyCode == 13 ){ if(window["gf_submitting_15"]){return false;} if( !jQuery("#gform_15")[0].checkValidity || jQuery("#gform_15")[0].checkValidity()){window["gf_submitting_15"]=true;} jQuery("#gform_15").trigger("submit",[true]); }">
<input type="hidden" class="gform_hidden" name="is_submit_15" value="1">
<input type="hidden" class="gform_hidden" name="gform_submit" value="15">
<input type="hidden" class="gform_hidden" name="gform_unique_id" value="">
<input type="hidden" class="gform_hidden" name="state_15" value="WyJbXSIsIjIyZDg5ZTVjZWRhYTEzY2EyMjdhNzkzNTllOWFkYTUxIl0=">
<input type="hidden" class="gform_hidden" name="gform_target_page_number_15" id="gform_target_page_number_15" value="0">
<input type="hidden" class="gform_hidden" name="gform_source_page_number_15" id="gform_source_page_number_15" value="1">
<input type="hidden" name="gform_field_values" value="">
</div>
</form>POST /
<form method="post" enctype="multipart/form-data" id="gform_14" action="/" data-formid="14" novalidate="">
<div class="gform-body gform_body">
<div id="gform_fields_14" class="gform_fields top_label form_sublabel_below description_below validation_below">
<div id="field_14_1" class="gfield gfield--type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible"
data-js-reload="field_14_1">
<div class="frm-title">Request to Register for Online Services</div>
<div class="fr-name">Your details</div>
</div>
<div id="field_14_5" class="gfield gfield--type-text gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible" data-js-reload="field_14_5">
<label class="gfield_label gform-field-label" for="input_14_5">First name:<span class="gfield_required"><span class="gfield_required gfield_required_text">(Required)</span></span></label>
<div class="ginput_container ginput_container_text"><input name="input_5" id="input_14_5" type="text" value="" class="large" aria-required="true" aria-invalid="false"> </div>
</div>
<div id="field_14_7" class="gfield gfield--type-text gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible" data-js-reload="field_14_7">
<label class="gfield_label gform-field-label" for="input_14_7">Last name:<span class="gfield_required"><span class="gfield_required gfield_required_text">(Required)</span></span></label>
<div class="ginput_container ginput_container_text"><input name="input_7" id="input_14_7" type="text" value="" class="large" aria-required="true" aria-invalid="false"> </div>
</div>
<div id="field_14_9"
class="gfield gfield--type-date gfield--input-type-datepicker gfield--datepicker-default-icon gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible"
data-js-reload="field_14_9"><label class="gfield_label gform-field-label" for="input_14_9">Date of birth:<span class="gfield_required"><span class="gfield_required gfield_required_text">(Required)</span></span></label>
<div class="ginput_container ginput_container_date">
<input name="input_9" id="input_14_9" type="text" value="" class="datepicker gform-datepicker dmy datepicker_with_icon gdatepicker_with_icon hasDatepicker initialized" placeholder="dd/mm/yyyy" aria-describedby="input_14_9_date_format"
aria-invalid="false" aria-required="true"><img class="ui-datepicker-trigger" src="https://nhsgp.net/wp-content/plugins/gravityforms/images/datepicker/datepicker.svg" alt="Select date" title="Select date">
<span id="input_14_9_date_format" class="screen-reader-text">DD slash MM slash YYYY</span>
</div>
<input type="hidden" id="gforms_calendar_icon_input_14_9" class="gform_hidden" value="https://nhsgp.net/wp-content/plugins/gravityforms/images/datepicker/datepicker.svg">
</div>
<div id="field_14_22" class="gfield gfield--type-text gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible" data-js-reload="field_14_22"><label
class="gfield_label gform-field-label" for="input_14_22">Postcode:</label>
<div class="ginput_container ginput_container_text"><input name="input_22" id="input_14_22" type="text" value="" class="large" aria-invalid="false"> </div>
</div>
<div id="field_14_11" class="gfield gfield--type-phone gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible"
data-js-reload="field_14_11"><label class="gfield_label gform-field-label" for="input_14_11">Home tel::<span class="gfield_required"><span class="gfield_required gfield_required_text">(Required)</span></span></label>
<div class="ginput_container ginput_container_phone"><input name="input_11" id="input_14_11" type="tel" value="" class="large" aria-required="true" aria-invalid="false"></div>
</div>
<div id="field_14_13" class="gfield gfield--type-phone gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible" data-js-reload="field_14_13"><label
class="gfield_label gform-field-label" for="input_14_13">Mobile:</label>
<div class="ginput_container ginput_container_phone"><input name="input_13" id="input_14_13" type="tel" value="" class="large" aria-invalid="false"></div>
</div>
<div id="field_14_10" class="gfield gfield--type-email gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible" data-js-reload="field_14_10"><label
class="gfield_label gform-field-label" for="input_14_10">Email</label>
<div class="ginput_container ginput_container_email">
<input name="input_10" id="input_14_10" type="email" value="" class="large" aria-invalid="false">
</div>
</div>
</div>
</div>
<div class="gform_footer top_label"> <input type="submit" id="gform_submit_button_14" class="gform_button button" value="Send"
onclick="if(window["gf_submitting_14"]){return false;} if( !jQuery("#gform_14")[0].checkValidity || jQuery("#gform_14")[0].checkValidity()){window["gf_submitting_14"]=true;} "
onkeypress="if( event.keyCode == 13 ){ if(window["gf_submitting_14"]){return false;} if( !jQuery("#gform_14")[0].checkValidity || jQuery("#gform_14")[0].checkValidity()){window["gf_submitting_14"]=true;} jQuery("#gform_14").trigger("submit",[true]); }">
<input type="hidden" class="gform_hidden" name="is_submit_14" value="1">
<input type="hidden" class="gform_hidden" name="gform_submit" value="14">
<input type="hidden" class="gform_hidden" name="gform_unique_id" value="">
<input type="hidden" class="gform_hidden" name="state_14" value="WyJbXSIsIjIyZDg5ZTVjZWRhYTEzY2EyMjdhNzkzNTllOWFkYTUxIl0=">
<input type="hidden" class="gform_hidden" name="gform_target_page_number_14" id="gform_target_page_number_14" value="0">
<input type="hidden" class="gform_hidden" name="gform_source_page_number_14" id="gform_source_page_number_14" value="1">
<input type="hidden" name="gform_field_values" value="">
</div>
</form>POST /
<form method="post" enctype="multipart/form-data" id="gform_13" action="/" data-formid="13" novalidate="">
<div class="gform-body gform_body">
<div id="gform_fields_13" class="gform_fields top_label form_sublabel_below description_below validation_below">
<div id="field_13_1" class="gfield gfield--type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible"
data-js-reload="field_13_1">
<div class="frm-title">Signing Up For Patient Reference Group</div>
<div class="frm-desc">If you are happy for us to contact you periodically by email please fill out all the fields below and send the completed form to us.</div>
</div>
<div id="field_13_3"
class="gfield gfield--type-html gfield--width-full bold-text gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible"
data-js-reload="field_13_3">Your details </div>
<div id="field_13_4" class="gfield gfield--type-select gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible" data-js-reload="field_13_4"><label
class="gfield_label gform-field-label" for="input_13_4">Title:</label>
<div class="ginput_container ginput_container_select"><select name="input_4" id="input_13_4" class="large gfield_select" aria-invalid="false">
<option value="Mr.">Mr.</option>
<option value="Mrs.">Mrs.</option>
<option value="Miss.">Miss.</option>
<option value="Ms.">Ms.</option>
</select></div>
</div>
<div id="field_13_5"
class="gfield gfield--type-date gfield--input-type-datepicker gfield--datepicker-default-icon gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible"
data-js-reload="field_13_5"><label class="gfield_label gform-field-label" for="input_13_5">Date of birth:<span class="gfield_required"><span class="gfield_required gfield_required_text">(Required)</span></span></label>
<div class="ginput_container ginput_container_date">
<input name="input_5" id="input_13_5" type="text" value="" class="datepicker gform-datepicker dmy datepicker_with_icon gdatepicker_with_icon hasDatepicker initialized" placeholder="dd/mm/yyyy" aria-describedby="input_13_5_date_format"
aria-invalid="false" aria-required="true"><img class="ui-datepicker-trigger" src="https://nhsgp.net/wp-content/plugins/gravityforms/images/datepicker/datepicker.svg" alt="Select date" title="Select date">
<span id="input_13_5_date_format" class="screen-reader-text">DD slash MM slash YYYY</span>
</div>
<input type="hidden" id="gforms_calendar_icon_input_13_5" class="gform_hidden" value="https://nhsgp.net/wp-content/plugins/gravityforms/images/datepicker/datepicker.svg">
</div>
<div id="field_13_6" class="gfield gfield--type-text gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible" data-js-reload="field_13_6">
<label class="gfield_label gform-field-label" for="input_13_6">First name:<span class="gfield_required"><span class="gfield_required gfield_required_text">(Required)</span></span></label>
<div class="ginput_container ginput_container_text"><input name="input_6" id="input_13_6" type="text" value="" class="large" aria-required="true" aria-invalid="false"> </div>
</div>
<div id="field_13_7" class="gfield gfield--type-text gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible" data-js-reload="field_13_7">
<label class="gfield_label gform-field-label" for="input_13_7">Surname:<span class="gfield_required"><span class="gfield_required gfield_required_text">(Required)</span></span></label>
<div class="ginput_container ginput_container_text"><input name="input_7" id="input_13_7" type="text" value="" class="large" aria-required="true" aria-invalid="false"> </div>
</div>
<div id="field_13_8" class="gfield gfield--type-text gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible" data-js-reload="field_13_8">
<label class="gfield_label gform-field-label" for="input_13_8">Email:<span class="gfield_required"><span class="gfield_required gfield_required_text">(Required)</span></span></label>
<div class="ginput_container ginput_container_text"><input name="input_8" id="input_13_8" type="text" value="" class="large" aria-required="true" aria-invalid="false"> </div>
</div>
<div id="field_13_9" class="gfield gfield--type-text gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible" data-js-reload="field_13_9">
<label class="gfield_label gform-field-label" for="input_13_9">Postcode:<span class="gfield_required"><span class="gfield_required gfield_required_text">(Required)</span></span></label>
<div class="ginput_container ginput_container_text"><input name="input_9" id="input_13_9" type="text" value="" class="large" aria-required="true" aria-invalid="false"> </div>
</div>
<div id="field_13_10" class="gfield gfield--type-phone gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible"
data-js-reload="field_13_10"><label class="gfield_label gform-field-label" for="input_13_10">Telephone:<span class="gfield_required"><span class="gfield_required gfield_required_text">(Required)</span></span></label>
<div class="ginput_container ginput_container_phone"><input name="input_10" id="input_13_10" type="tel" value="" class="large" aria-required="true" aria-invalid="false"></div>
</div>
<div id="field_13_11"
class="gfield gfield--type-html gfield--width-full bold-text gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible"
data-js-reload="field_13_11">The information below will help to make sure that we receive feedback from a representative sample of the patients registered at this practice. </div>
<fieldset id="field_13_12" class="gfield gfield--type-radio gfield--type-choice gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible"
data-js-reload="field_13_12">
<legend class="gfield_label gform-field-label">Your Gender</legend>
<div class="ginput_container ginput_container_radio">
<div class="gfield_radio" id="input_13_12">
<div class="gchoice gchoice_13_12_0">
<input class="gfield-choice-input" name="input_12" type="radio" value="Male" id="choice_13_12_0" onchange="gformToggleRadioOther( this )">
<label for="choice_13_12_0" id="label_13_12_0" class="gform-field-label gform-field-label--type-inline">Male</label>
</div>
<div class="gchoice gchoice_13_12_1">
<input class="gfield-choice-input" name="input_12" type="radio" value="Female" id="choice_13_12_1" onchange="gformToggleRadioOther( this )">
<label for="choice_13_12_1" id="label_13_12_1" class="gform-field-label gform-field-label--type-inline">Female</label>
</div>
</div>
</div>
</fieldset>
<fieldset id="field_13_13" class="gfield gfield--type-radio gfield--type-choice gfield--width-full lists2 field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible"
data-js-reload="field_13_13">
<legend class="gfield_label gform-field-label">Your Age</legend>
<div class="ginput_container ginput_container_radio">
<div class="gfield_radio" id="input_13_13">
<div class="gchoice gchoice_13_13_0">
<input class="gfield-choice-input" name="input_13" type="radio" value="Under 16" id="choice_13_13_0" onchange="gformToggleRadioOther( this )">
<label for="choice_13_13_0" id="label_13_13_0" class="gform-field-label gform-field-label--type-inline">Under 16</label>
</div>
<div class="gchoice gchoice_13_13_1">
<input class="gfield-choice-input" name="input_13" type="radio" value="17-24" id="choice_13_13_1" onchange="gformToggleRadioOther( this )">
<label for="choice_13_13_1" id="label_13_13_1" class="gform-field-label gform-field-label--type-inline">17-24</label>
</div>
<div class="gchoice gchoice_13_13_2">
<input class="gfield-choice-input" name="input_13" type="radio" value="25-34" id="choice_13_13_2" onchange="gformToggleRadioOther( this )">
<label for="choice_13_13_2" id="label_13_13_2" class="gform-field-label gform-field-label--type-inline">25-34</label>
</div>
<div class="gchoice gchoice_13_13_3">
<input class="gfield-choice-input" name="input_13" type="radio" value="35-44" id="choice_13_13_3" onchange="gformToggleRadioOther( this )">
<label for="choice_13_13_3" id="label_13_13_3" class="gform-field-label gform-field-label--type-inline">35-44</label>
</div>
<div class="gchoice gchoice_13_13_4">
<input class="gfield-choice-input" name="input_13" type="radio" value="45-54" id="choice_13_13_4" onchange="gformToggleRadioOther( this )">
<label for="choice_13_13_4" id="label_13_13_4" class="gform-field-label gform-field-label--type-inline">45-54</label>
</div>
<div class="gchoice gchoice_13_13_5">
<input class="gfield-choice-input" name="input_13" type="radio" value="55-64" id="choice_13_13_5" onchange="gformToggleRadioOther( this )">
<label for="choice_13_13_5" id="label_13_13_5" class="gform-field-label gform-field-label--type-inline">55-64</label>
</div>
<div class="gchoice gchoice_13_13_6">
<input class="gfield-choice-input" name="input_13" type="radio" value="65-74" id="choice_13_13_6" onchange="gformToggleRadioOther( this )">
<label for="choice_13_13_6" id="label_13_13_6" class="gform-field-label gform-field-label--type-inline">65-74</label>
</div>
<div class="gchoice gchoice_13_13_7">
<input class="gfield-choice-input" name="input_13" type="radio" value="75-84" id="choice_13_13_7" onchange="gformToggleRadioOther( this )">
<label for="choice_13_13_7" id="label_13_13_7" class="gform-field-label gform-field-label--type-inline">75-84</label>
</div>
<div class="gchoice gchoice_13_13_8">
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<legend class="gfield_label gform-field-label">The ethnic background with which you most closely identify is:</legend>
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<legend class="gfield_label gform-field-label">How would you describe how often you come to the practice?</legend>
<div class="ginput_container ginput_container_radio">
<div class="gfield_radio" id="input_13_15">
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<label for="choice_13_15_1" id="label_13_15_1" class="gform-field-label gform-field-label--type-inline">Occasionally</label>
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<div id="field_11_1" class="gfield gfield--type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible"
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<div class="frm-title">The General Practice Assessment Questionnaire (GPAQ)</div>
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class="gfield_label gform-field-label" for="input_11_3">Firstly, please tell us the name of your usual doctor</label>
<div class="ginput_container ginput_container_select"><select name="input_3" id="input_11_3" class="large gfield_select" aria-invalid="false">
<option value="Dr Jahan Mahmoodi">Dr Jahan Mahmoodi</option>
<option value="Dr Vruti Patel">Dr Vruti Patel</option>
<option value="Dr Sarah Elhag">Dr Sarah Elhag</option>
<option value="Dr Bhavini Patel">Dr Bhavini Patel</option>
<option value="Dr Kanishka Samarasinghe">Dr Kanishka Samarasinghe</option>
<option value="Dr Marie Wilson">Dr Marie Wilson</option>
<option value="Dr Furquan Taher">Dr Furquan Taher</option>
<option value="Dr Ishani Patel">Dr Ishani Patel</option>
<option value="Dr Kamal Patel">Dr Kamal Patel</option>
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<div id="field_11_4" class="gfield gfield--type-select gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible" data-js-reload="field_11_4"><label
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class="gfield_label gform-field-label" for="input_11_5">2. How do you rate the way you are treated by receptionists at your practice?</label>
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<option value="Very poor">Very poor</option>
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<option value="Fair">Fair</option>
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class="gfield_label gform-field-label" for="input_11_6">3 a) How do you rate the hours that your practice is open for appointments?</label>
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<option value="Very poor">Very poor</option>
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<option value="Fair">Fair</option>
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<option value="Very good">Very good</option>
<option value="Excellent">Excellent</option>
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<legend class="gfield_label gform-field-label gfield_label_before_complex">3 b) What additional hours would you like the practice to be open? (please tick all that apply)</legend>
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<div class="gchoice gchoice_11_8_1">
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class="gfield_label gform-field-label" for="input_11_9">4 a) Thinking of times when you want to see a particular doctor, how quickly do you usually get to see that doctor?</label>
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<option value="Same day">Same day</option>
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<option value="Within 4 working days">Within 4 working days</option>
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<option value="Very poor">Very poor</option>
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<option value="Fair">Fair</option>
<option value="Good">Good</option>
<option value="Very good">Very good</option>
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<option value="Within 3 working days">Within 3 working days</option>
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<option value="Very poor">Very poor</option>
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<option value="Fair">Fair</option>
<option value="Good">Good</option>
<option value="Very good">Very good</option>
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<div id="field_11_13" class="gfield gfield--type-select gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible" data-js-reload="field_11_13"><label
class="gfield_label gform-field-label" for="input_11_13">6. If you need to see a GP urgently, can you normally get seen on the same day?</label>
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<option value="Yes">Yes</option>
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<div id="field_11_14" class="gfield gfield--type-select gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible" data-js-reload="field_11_14"><label
class="gfield_label gform-field-label" for="input_11_14">7. a) How long do you usually have to wait at the practice for your consultations to begin?</label>
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<option value="5 minutes or less">5 minutes or less</option>
<option value="6-10 minutes">6-10 minutes</option>
<option value="11-20 minutes">11-20 minutes</option>
<option value="21-30 minutes">21-30 minutes</option>
<option value="More than 30 minutes">More than 30 minutes</option>
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</div>
<div id="field_11_16" class="gfield gfield--type-select gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible" data-js-reload="field_11_16"><label
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<option value="Very poor">Very poor</option>
<option value="Poor">Poor</option>
<option value="Fair">Fair</option>
<option value="Good">Good</option>
<option value="Very good">Very good</option>
<option value="Excellent">Excellent</option>
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<div id="field_11_17" class="gfield gfield--type-select gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible" data-js-reload="field_11_17"><label
class="gfield_label gform-field-label" for="input_11_17">8 a) Thinking of times you have phoned the practice, how do you rate the ability to get through to the practice on the phone?</label>
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<option value="Very poor">Very poor</option>
<option value="Poor">Poor</option>
<option value="Fair">Fair</option>
<option value="Good">Good</option>
<option value="Very good">Very good</option>
<option value="Excellent">Excellent</option>
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<div id="field_11_18" class="gfield gfield--type-select gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible" data-js-reload="field_11_18"><label
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<option value="Very poor">Very poor</option>
<option value="Poor">Poor</option>
<option value="Fair">Fair</option>
<option value="Good">Good</option>
<option value="Very good">Very good</option>
<option value="Excellent">Excellent</option>
<option value="Don't know/Never tried">Don't know/Never tried</option>
</select></div>
</div>
<div id="field_11_19" class="gfield gfield--type-select gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible" data-js-reload="field_11_19"><label
class="gfield_label gform-field-label" for="input_11_19">9 a) In general, how often do you see your usual doctor?</label>
<div class="ginput_container ginput_container_select"><select name="input_19" id="input_11_19" class="large gfield_select" aria-invalid="false">
<option value="Always">Always</option>
<option value="Almost always">Almost always</option>
<option value="A lot of the time">A lot of the time</option>
<option value="Some of the time">Some of the time</option>
<option value="Almost never">Almost never</option>
<option value="Never">Never</option>
</select></div>
</div>
<div id="field_11_20" class="gfield gfield--type-select gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible" data-js-reload="field_11_20"><label
class="gfield_label gform-field-label" for="input_11_20">9 b) How do you rate this?</label>
<div class="ginput_container ginput_container_select"><select name="input_20" id="input_11_20" class="large gfield_select" aria-invalid="false">
<option value="Very poor">Very poor</option>
<option value="Poor">Poor</option>
<option value="Fair">Fair</option>
<option value="Good">Good</option>
<option value="Very good">Very good</option>
<option value="Excellent">Excellent</option>
</select></div>
</div>
<div id="field_11_21" class="gfield gfield--type-select gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible" data-js-reload="field_11_21"><label
class="gfield_label gform-field-label" for="input_11_21">10 a) Thinking about when you consult your doctor, how thoroughly the doctor asked about your symptoms and how you are feeling?</label>
<div class="ginput_container ginput_container_select"><select name="input_21" id="input_11_21" class="large gfield_select" aria-invalid="false">
<option value="Very poor">Very poor</option>
<option value="Poor">Poor</option>
<option value="Fair">Fair</option>
<option value="Good">Good</option>
<option value="Very good">Very good</option>
<option value="Excellent">Excellent</option>
<option value="Does not apply">Does not apply</option>
</select></div>
</div>
<div id="field_11_22" class="gfield gfield--type-select gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible" data-js-reload="field_11_22"><label
class="gfield_label gform-field-label" for="input_11_22">10 b) How well the doctor listens to what you had to say?</label>
<div class="ginput_container ginput_container_select"><select name="input_22" id="input_11_22" class="large gfield_select" aria-invalid="false">
<option value="Very poor">Very poor</option>
<option value="Poor">Poor</option>
<option value="Fair">Fair</option>
<option value="Good">Good</option>
<option value="Very good">Very good</option>
<option value="Excellent">Excellent</option>
<option value="Does not apply">Does not apply</option>
</select></div>
</div>
<div id="field_11_23" class="gfield gfield--type-select gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible" data-js-reload="field_11_23"><label
class="gfield_label gform-field-label" for="input_11_23">10 c) How well the doctor puts you at ease during your physical examination?</label>
<div class="ginput_container ginput_container_select"><select name="input_23" id="input_11_23" class="large gfield_select" aria-invalid="false">
<option value="Very poor">Very poor</option>
<option value="Poor">Poor</option>
<option value="Fair">Fair</option>
<option value="Good">Good</option>
<option value="Very good">Very good</option>
<option value="Excellent">Excellent</option>
<option value="Does not apply">Does not apply</option>
</select></div>
</div>
<div id="field_11_24" class="gfield gfield--type-select gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible" data-js-reload="field_11_24"><label
class="gfield_label gform-field-label" for="input_11_24">10 d) How much the doctor involves you in decisions about your care?</label>
<div class="ginput_container ginput_container_select"><select name="input_24" id="input_11_24" class="large gfield_select" aria-invalid="false">
<option value="Very poor">Very poor</option>
<option value="Poor">Poor</option>
<option value="Fair">Fair</option>
<option value="Good">Good</option>
<option value="Very good">Very good</option>
<option value="Excellent">Excellent</option>
<option value="Does not apply">Does not apply</option>
</select></div>
</div>
<div id="field_11_25" class="gfield gfield--type-select gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible" data-js-reload="field_11_25"><label
class="gfield_label gform-field-label" for="input_11_25">10 e) How well the doctor explains your problems or any treatment that you need?</label>
<div class="ginput_container ginput_container_select"><select name="input_25" id="input_11_25" class="large gfield_select" aria-invalid="false">
<option value="Very poor">Very poor</option>
<option value="Poor">Poor</option>
<option value="Fair">Fair</option>
<option value="Good">Good</option>
<option value="Very good">Very good</option>
<option value="Excellent">Excellent</option>
<option value="Does not apply">Does not apply</option>
</select></div>
</div>
<div id="field_11_26" class="gfield gfield--type-select gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible" data-js-reload="field_11_26"><label
class="gfield_label gform-field-label" for="input_11_26">10 f) The amount of time your doctor spends with you?</label>
<div class="ginput_container ginput_container_select"><select name="input_26" id="input_11_26" class="large gfield_select" aria-invalid="false">
<option value="Very poor">Very poor</option>
<option value="Poor">Poor</option>
<option value="Fair">Fair</option>
<option value="Good">Good</option>
<option value="Very good">Very good</option>
<option value="Excellent">Excellent</option>
</select></div>
</div>
<div id="field_11_27" class="gfield gfield--type-select gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible" data-js-reload="field_11_27"><label
class="gfield_label gform-field-label" for="input_11_27">10 g) The doctor's patience with your questions or worries?</label>
<div class="ginput_container ginput_container_select"><select name="input_27" id="input_11_27" class="large gfield_select" aria-invalid="false">
<option value="Very poor">Very poor</option>
<option value="Poor">Poor</option>
<option value="Fair">Fair</option>
<option value="Good">Good</option>
<option value="Very good">Very good</option>
<option value="Excellent">Excellent</option>
<option value="Does not apply">Does not apply</option>
</select></div>
</div>
<div id="field_11_28" class="gfield gfield--type-select gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible" data-js-reload="field_11_28"><label
class="gfield_label gform-field-label" for="input_11_28">10 h) The doctor's caring and concern for you?</label>
<div class="ginput_container ginput_container_select"><select name="input_28" id="input_11_28" class="large gfield_select" aria-invalid="false">
<option value="Very poor">Very poor</option>
<option value="Poor">Poor</option>
<option value="Fair">Fair</option>
<option value="Good">Good</option>
<option value="Very good">Very good</option>
<option value="Excellent">Excellent</option>
<option value="Does not apply">Does not apply</option>
</select></div>
</div>
<div id="field_11_29" class="gfield gfield--type-select gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible" data-js-reload="field_11_29"><label
class="gfield_label gform-field-label" for="input_11_29">11) Have you seen a nurse from your practice in the past 12 months?</label>
<div class="ginput_container ginput_container_select"><select name="input_29" id="input_11_29" class="large gfield_select" aria-invalid="false">
<option value="Yes - go to question 12">Yes - go to question 12</option>
<option value="No - go to question 13">No - go to question 13</option>
</select></div>
</div>
<div id="field_11_30" class="gfield gfield--type-select gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible" data-js-reload="field_11_30"><label
class="gfield_label gform-field-label" for="input_11_30">12 a) Thinking about the nurse(s) you have seen, how do you rate the following: How well they listen to what you say?</label>
<div class="ginput_container ginput_container_select"><select name="input_30" id="input_11_30" class="large gfield_select" aria-invalid="false">
<option value="Very poor">Very poor</option>
<option value="Poor">Poor</option>
<option value="Fair">Fair</option>
<option value="Good">Good</option>
<option value="Very good">Very good</option>
</select></div>
</div>
<div id="field_11_31" class="gfield gfield--type-select gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible" data-js-reload="field_11_31"><label
class="gfield_label gform-field-label" for="input_11_31">12 b) The quality of care they provide?</label>
<div class="ginput_container ginput_container_select"><select name="input_31" id="input_11_31" class="large gfield_select" aria-invalid="false">
<option value="Very poor">Very poor</option>
<option value="Poor">Poor</option>
<option value="Fair">Fair</option>
<option value="Good">Good</option>
<option value="Very good">Very good</option>
<option value="Excellent">Excellent</option>
</select></div>
</div>
<div id="field_11_32" class="gfield gfield--type-select gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible" data-js-reload="field_11_32"><label
class="gfield_label gform-field-label" for="input_11_32">12 c) How well they explain your health problems or any treatment that you need?</label>
<div class="ginput_container ginput_container_select"><select name="input_32" id="input_11_32" class="large gfield_select" aria-invalid="false">
<option value="Very poor">Very poor</option>
<option value="Poor">Poor</option>
<option value="Fair">Fair</option>
<option value="Good">Good</option>
<option value="Very good">Very good</option>
<option value="Excellent">Excellent</option>
</select></div>
</div>
<div id="field_11_33" class="gfield gfield--type-select gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible" data-js-reload="field_11_33"><label
class="gfield_label gform-field-label" for="input_11_33">13) Are you:</label>
<div class="ginput_container ginput_container_select"><select name="input_33" id="input_11_33" class="large gfield_select" aria-invalid="false">
<option value="Male">Male</option>
<option value="Female">Female</option>
</select></div>
</div>
<div id="field_11_34" class="gfield gfield--type-select gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible" data-js-reload="field_11_34"><label
class="gfield_label gform-field-label" for="input_11_34">14) How old are you?</label>
<div class="ginput_container ginput_container_select"><select name="input_34" id="input_11_34" class="large gfield_select" aria-invalid="false">
<option value="0-15">0-15</option>
<option value="16-24">16-24</option>
<option value="24-35">24-35</option>
<option value="36-50">36-50</option>
<option value="50-65">50-65</option>
<option value="65 and over">65 and over</option>
</select></div>
</div>
<div id="field_11_35" class="gfield gfield--type-select gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible" data-js-reload="field_11_35"><label
class="gfield_label gform-field-label" for="input_11_35">15) Do you have any long-standing illness, disability or infirmity? By long-standing we mean anything that has troubled you over a period of time or that is likely to affect you over
a period of time.</label>
<div class="ginput_container ginput_container_select"><select name="input_35" id="input_11_35" class="large gfield_select" aria-invalid="false">
<option value="Yes">Yes</option>
<option value="No">No</option>
</select></div>
</div>
<div id="field_11_36" class="gfield gfield--type-select gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible" data-js-reload="field_11_36"><label
class="gfield_label gform-field-label" for="input_11_36">16) Which ethnic group do you belong to?</label>
<div class="ginput_container ginput_container_select"><select name="input_36" id="input_11_36" class="large gfield_select" aria-invalid="false">
<option value="White">White</option>
<option value="Black or Black British">Black or Black British</option>
<option value="Asian or Asian British">Asian or Asian British</option>
<option value="Mixed">Mixed</option>
<option value="Chinese">Chinese</option>
<option value="Other Ethnic Group">Other Ethnic Group</option>
</select></div>
</div>
<div id="field_11_37" class="gfield gfield--type-select gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible" data-js-reload="field_11_37"><label
class="gfield_label gform-field-label" for="input_11_37">17) Is your accommodation?</label>
<div class="ginput_container ginput_container_select"><select name="input_37" id="input_11_37" class="large gfield_select" aria-invalid="false">
<option value="Owner occupied/mortgaged">Owner occupied/mortgaged</option>
<option value="Rented or other arrangements">Rented or other arrangements</option>
</select></div>
</div>
<div id="field_11_38" class="gfield gfield--type-select gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible" data-js-reload="field_11_38"><label
class="gfield_label gform-field-label" for="input_11_38">18) Which of the following best describes you?</label>
<div class="ginput_container ginput_container_select"><select name="input_38" id="input_11_38" class="large gfield_select" aria-invalid="false">
<option value="Employed (full or part-time, including self-employed)">Employed (full or part-time, including self-employed)</option>
<option value="Unemployed and looking for work">Unemployed and looking for work</option>
<option value="At school or in full time education">At school or in full time education</option>
<option value="Unable to work due to long term illness">Unable to work due to long term illness</option>
<option value="Looking after your home/family">Looking after your home/family</option>
<option value="Retired">Retired</option>
<option value="Other">Other</option>
</select></div>
</div>
<div id="field_11_39" class="gfield gfield--type-textarea gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible" data-js-reload="field_11_39"><label
class="gfield_label gform-field-label" for="input_11_39">19) We are interested in any other comments you may have. Please enter them below.</label>
<div class="ginput_container ginput_container_textarea"><textarea name="input_39" id="input_11_39" class="textarea small"
placeholder="Is there anything particularly good about your healthcare... is there anything that could be improved... Do you have any other comments?" aria-invalid="false" rows="10" cols="50"></textarea></div>
</div>
</div>
</div>
<div class="gform_footer top_label"> <input type="submit" id="gform_submit_button_11" class="gform_button button" value="Submit"
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<input type="hidden" name="gform_field_values" value="">
</div>
</form>POST /
<form method="post" enctype="multipart/form-data" id="gform_8" action="/" data-formid="8" novalidate="">
<div class="gform-body gform_body">
<div id="gform_fields_8" class="gform_fields top_label form_sublabel_below description_below validation_below">
<div id="field_8_8"
class="gfield gfield--type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible"
data-js-reload="field_8_8">
<div class="frm-title">Travel Questionnaire</div>
</div>
<div id="field_8_1" class="gfield gfield--type-html bold-text gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible"
data-js-reload="field_8_1">Personal Details</div>
<div id="field_8_3" class="gfield gfield--type-text gfield--width-third gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible" data-js-reload="field_8_3">
<label class="gfield_label gform-field-label" for="input_8_3">Name:<span class="gfield_required"><span class="gfield_required gfield_required_text">(Required)</span></span></label>
<div class="ginput_container ginput_container_text"><input name="input_3" id="input_8_3" type="text" value="" class="large" aria-required="true" aria-invalid="false"> </div>
</div>
<div id="field_8_4" class="gfield gfield--type-select gfield--width-third field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible" data-js-reload="field_8_4"><label
class="gfield_label gform-field-label" for="input_8_4">Sex:</label>
<div class="ginput_container ginput_container_select"><select name="input_4" id="input_8_4" class="large gfield_select" aria-invalid="false">
<option value="Male">Male</option>
<option value="Female">Female</option>
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</div>
<div id="field_8_5"
class="gfield gfield--type-date gfield--input-type-datepicker gfield--datepicker-default-icon gfield--width-third gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible"
data-js-reload="field_8_5"><label class="gfield_label gform-field-label" for="input_8_5">Date of birth:<span class="gfield_required"><span class="gfield_required gfield_required_text">(Required)</span></span></label>
<div class="ginput_container ginput_container_date">
<input name="input_5" id="input_8_5" type="text" value="" class="datepicker gform-datepicker mdy datepicker_with_icon gdatepicker_with_icon hasDatepicker initialized" placeholder="mm/dd/yyyy" aria-describedby="input_8_5_date_format"
aria-invalid="false" aria-required="true"><img class="ui-datepicker-trigger" src="https://nhsgp.net/wp-content/plugins/gravityforms/images/datepicker/datepicker.svg" alt="Select date" title="Select date">
<span id="input_8_5_date_format" class="screen-reader-text">MM slash DD slash YYYY</span>
</div>
<input type="hidden" id="gforms_calendar_icon_input_8_5" class="gform_hidden" value="https://nhsgp.net/wp-content/plugins/gravityforms/images/datepicker/datepicker.svg">
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<div id="field_8_6" class="gfield gfield--type-phone gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible" data-js-reload="field_8_6">
<label class="gfield_label gform-field-label" for="input_8_6">Daytime tel:<span class="gfield_required"><span class="gfield_required gfield_required_text">(Required)</span></span></label>
<div class="ginput_container ginput_container_phone"><input name="input_6" id="input_8_6" type="tel" value="" class="large" aria-required="true" aria-invalid="false"></div>
</div>
<div id="field_8_7" class="gfield gfield--type-text gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible" data-js-reload="field_8_7">
<label class="gfield_label gform-field-label" for="input_8_7">Postcode:<span class="gfield_required"><span class="gfield_required gfield_required_text">(Required)</span></span></label>
<div class="ginput_container ginput_container_text"><input name="input_7" id="input_8_7" type="text" value="" class="large" aria-required="true" aria-invalid="false"> </div>
</div>
<div id="field_8_9" class="gfield gfield--type-email gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible" data-js-reload="field_8_9">
<label class="gfield_label gform-field-label" for="input_8_9">Email:<span class="gfield_required"><span class="gfield_required gfield_required_text">(Required)</span></span></label>
<div class="ginput_container ginput_container_email">
<input name="input_9" id="input_8_9" type="email" value="" class="large" aria-required="true" aria-invalid="false">
</div>
</div>
<div id="field_8_11"
class="gfield gfield--type-html gfield--width-full bold-text gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible"
data-js-reload="field_8_11">Trip Dates</div>
<div id="field_8_12"
class="gfield gfield--type-date gfield--input-type-datepicker gfield--datepicker-default-icon gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible"
data-js-reload="field_8_12"><label class="gfield_label gform-field-label" for="input_8_12">Trip departure:<span class="gfield_required"><span class="gfield_required gfield_required_text">(Required)</span></span></label>
<div class="ginput_container ginput_container_date">
<input name="input_12" id="input_8_12" type="text" value="" class="datepicker gform-datepicker dmy datepicker_with_icon gdatepicker_with_icon hasDatepicker initialized" placeholder="dd/mm/yyyy" aria-describedby="input_8_12_date_format"
aria-invalid="false" aria-required="true"><img class="ui-datepicker-trigger" src="https://nhsgp.net/wp-content/plugins/gravityforms/images/datepicker/datepicker.svg" alt="Select date" title="Select date">
<span id="input_8_12_date_format" class="screen-reader-text">DD slash MM slash YYYY</span>
</div>
<input type="hidden" id="gforms_calendar_icon_input_8_12" class="gform_hidden" value="https://nhsgp.net/wp-content/plugins/gravityforms/images/datepicker/datepicker.svg">
</div>
<div id="field_8_13" class="gfield gfield--type-text gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible" data-js-reload="field_8_13">
<label class="gfield_label gform-field-label" for="input_8_13">Trip duration:<span class="gfield_required"><span class="gfield_required gfield_required_text">(Required)</span></span></label>
<div class="ginput_container ginput_container_text"><input name="input_13" id="input_8_13" type="text" value="" class="large" aria-required="true" aria-invalid="false"> </div>
</div>
<div id="field_8_14"
class="gfield gfield--type-html gfield--width-full bold-text gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible"
data-js-reload="field_8_14">Itinerary</div>
<div id="field_8_15" class="gfield gfield--type-text gfield--width-third gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible" data-js-reload="field_8_15">
<label class="gfield_label gform-field-label" for="input_8_15">Country:<span class="gfield_required"><span class="gfield_required gfield_required_text">(Required)</span></span></label>
<div class="ginput_container ginput_container_text"><input name="input_15" id="input_8_15" type="text" value="" class="large" aria-required="true" aria-invalid="false"> </div>
</div>
<div id="field_8_16" class="gfield gfield--type-text gfield--width-third gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible" data-js-reload="field_8_16">
<label class="gfield_label gform-field-label" for="input_8_16">Duration:<span class="gfield_required"><span class="gfield_required gfield_required_text">(Required)</span></span></label>
<div class="ginput_container ginput_container_text"><input name="input_16" id="input_8_16" type="text" value="" class="large" aria-required="true" aria-invalid="false"> </div>
</div>
<div id="field_8_20" class="gfield gfield--type-text gfield--width-third field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible" data-js-reload="field_8_20"><label
class="gfield_label gform-field-label" for="input_8_20">Availability of medical help:</label>
<div class="ginput_container ginput_container_text"><input name="input_20" id="input_8_20" type="text" value="" class="large" aria-invalid="false"> </div>
</div>
<div id="field_8_21" class="gfield gfield--type-text gfield--width-third gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible" data-js-reload="field_8_21">
<label class="gfield_label gform-field-label" for="input_8_21">Country:<span class="gfield_required"><span class="gfield_required gfield_required_text">(Required)</span></span></label>
<div class="ginput_container ginput_container_text"><input name="input_21" id="input_8_21" type="text" value="" class="large" aria-required="true" aria-invalid="false"> </div>
</div>
<div id="field_8_22" class="gfield gfield--type-text gfield--width-third field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible" data-js-reload="field_8_22"><label
class="gfield_label gform-field-label" for="input_8_22">Duration:</label>
<div class="ginput_container ginput_container_text"><input name="input_22" id="input_8_22" type="text" value="" class="large" aria-invalid="false"> </div>
</div>
<div id="field_8_23" class="gfield gfield--type-text gfield--width-third field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible" data-js-reload="field_8_23"><label
class="gfield_label gform-field-label" for="input_8_23">Availability of medical help:</label>
<div class="ginput_container ginput_container_text"><input name="input_23" id="input_8_23" type="text" value="" class="large" aria-invalid="false"> </div>
</div>
<div id="field_8_24" class="gfield gfield--type-text gfield--width-third field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible" data-js-reload="field_8_24"><label
class="gfield_label gform-field-label" for="input_8_24">Country:</label>
<div class="ginput_container ginput_container_text"><input name="input_24" id="input_8_24" type="text" value="" class="large" aria-invalid="false"> </div>
</div>
<div id="field_8_25" class="gfield gfield--type-text gfield--width-third field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible" data-js-reload="field_8_25"><label
class="gfield_label gform-field-label" for="input_8_25">Duration:</label>
<div class="ginput_container ginput_container_text"><input name="input_25" id="input_8_25" type="text" value="" class="large" aria-invalid="false"> </div>
</div>
<div id="field_8_26" class="gfield gfield--type-text gfield--width-third field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible" data-js-reload="field_8_26"><label
class="gfield_label gform-field-label" for="input_8_26">Availability of medical help:</label>
<div class="ginput_container ginput_container_text"><input name="input_26" id="input_8_26" type="text" value="" class="large" aria-invalid="false"> </div>
</div>
<div id="field_8_27" class="gfield gfield--type-text gfield--width-third field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible" data-js-reload="field_8_27"><label
class="gfield_label gform-field-label" for="input_8_27">Country:</label>
<div class="ginput_container ginput_container_text"><input name="input_27" id="input_8_27" type="text" value="" class="large" aria-invalid="false"> </div>
</div>
<div id="field_8_28" class="gfield gfield--type-text gfield--width-third field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible" data-js-reload="field_8_28"><label
class="gfield_label gform-field-label" for="input_8_28">Duration:</label>
<div class="ginput_container ginput_container_text"><input name="input_28" id="input_8_28" type="text" value="" class="large" aria-invalid="false"> </div>
</div>
<div id="field_8_29" class="gfield gfield--type-text gfield--width-third field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible" data-js-reload="field_8_29"><label
class="gfield_label gform-field-label" for="input_8_29">Availability of medical help:</label>
<div class="ginput_container ginput_container_text"><input name="input_29" id="input_8_29" type="text" value="" class="large" aria-invalid="false"> </div>
</div>
<div id="field_8_30" class="gfield gfield--type-text gfield--width-third field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible" data-js-reload="field_8_30"><label
class="gfield_label gform-field-label" for="input_8_30">Country:</label>
<div class="ginput_container ginput_container_text"><input name="input_30" id="input_8_30" type="text" value="" class="large" aria-invalid="false"> </div>
</div>
<div id="field_8_31" class="gfield gfield--type-text gfield--width-third field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible" data-js-reload="field_8_31"><label
class="gfield_label gform-field-label" for="input_8_31">Duration:</label>
<div class="ginput_container ginput_container_text"><input name="input_31" id="input_8_31" type="text" value="" class="large" aria-invalid="false"> </div>
</div>
<div id="field_8_32" class="gfield gfield--type-text gfield--width-third field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible" data-js-reload="field_8_32"><label
class="gfield_label gform-field-label" for="input_8_32">Availability of medical help:</label>
<div class="ginput_container ginput_container_text"><input name="input_32" id="input_8_32" type="text" value="" class="large" aria-invalid="false"> </div>
</div>
<div id="field_8_33"
class="gfield gfield--type-html gfield--width-full bold-text gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible"
data-js-reload="field_8_33">Trip Description - please tick all appropriate boxes: </div>
<fieldset id="field_8_34" class="gfield gfield--type-radio gfield--type-choice gfield--width-half lists field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible"
data-js-reload="field_8_34">
<legend class="gfield_label gform-field-label">Purpose of trip:</legend>
<div class="ginput_container ginput_container_radio">
<div class="gfield_radio" id="input_8_34">
<div class="gchoice gchoice_8_34_0">
<input class="gfield-choice-input" name="input_34" type="radio" value="Business" id="choice_8_34_0" onchange="gformToggleRadioOther( this )">
<label for="choice_8_34_0" id="label_8_34_0" class="gform-field-label gform-field-label--type-inline">Business</label>
</div>
<div class="gchoice gchoice_8_34_1">
<input class="gfield-choice-input" name="input_34" type="radio" value="Pleasure" id="choice_8_34_1" onchange="gformToggleRadioOther( this )">
<label for="choice_8_34_1" id="label_8_34_1" class="gform-field-label gform-field-label--type-inline">Pleasure</label>
</div>
<div class="gchoice gchoice_8_34_2">
<input class="gfield-choice-input" name="input_34" type="radio" value="Other" id="choice_8_34_2" onchange="gformToggleRadioOther( this )">
<label for="choice_8_34_2" id="label_8_34_2" class="gform-field-label gform-field-label--type-inline">Other</label>
</div>
</div>
</div>
</fieldset>
<fieldset id="field_8_35" class="gfield gfield--type-radio gfield--type-choice gfield--width-half lists field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible"
data-js-reload="field_8_35">
<legend class="gfield_label gform-field-label">Type of trip:</legend>
<div class="ginput_container ginput_container_radio">
<div class="gfield_radio" id="input_8_35">
<div class="gchoice gchoice_8_35_0">
<input class="gfield-choice-input" name="input_35" type="radio" value="Package" id="choice_8_35_0" onchange="gformToggleRadioOther( this )">
<label for="choice_8_35_0" id="label_8_35_0" class="gform-field-label gform-field-label--type-inline">Package</label>
</div>
<div class="gchoice gchoice_8_35_1">
<input class="gfield-choice-input" name="input_35" type="radio" value="Self-organised" id="choice_8_35_1" onchange="gformToggleRadioOther( this )">
<label for="choice_8_35_1" id="label_8_35_1" class="gform-field-label gform-field-label--type-inline">Self-organised</label>
</div>
<div class="gchoice gchoice_8_35_2">
<input class="gfield-choice-input" name="input_35" type="radio" value="Backpacking" id="choice_8_35_2" onchange="gformToggleRadioOther( this )">
<label for="choice_8_35_2" id="label_8_35_2" class="gform-field-label gform-field-label--type-inline">Backpacking</label>
</div>
<div class="gchoice gchoice_8_35_3">
<input class="gfield-choice-input" name="input_35" type="radio" value="Camping" id="choice_8_35_3" onchange="gformToggleRadioOther( this )">
<label for="choice_8_35_3" id="label_8_35_3" class="gform-field-label gform-field-label--type-inline">Camping</label>
</div>
<div class="gchoice gchoice_8_35_4">
<input class="gfield-choice-input" name="input_35" type="radio" value="Cruise ship" id="choice_8_35_4" onchange="gformToggleRadioOther( this )">
<label for="choice_8_35_4" id="label_8_35_4" class="gform-field-label gform-field-label--type-inline">Cruise ship</label>
</div>
<div class="gchoice gchoice_8_35_5">
<input class="gfield-choice-input" name="input_35" type="radio" value="Trekking" id="choice_8_35_5" onchange="gformToggleRadioOther( this )">
<label for="choice_8_35_5" id="label_8_35_5" class="gform-field-label gform-field-label--type-inline">Trekking</label>
</div>
</div>
</div>
</fieldset>
<fieldset id="field_8_36" class="gfield gfield--type-radio gfield--type-choice gfield--width-half lists field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible"
data-js-reload="field_8_36">
<legend class="gfield_label gform-field-label">Accomodation:</legend>
<div class="ginput_container ginput_container_radio">
<div class="gfield_radio" id="input_8_36">
<div class="gchoice gchoice_8_36_0">
<input class="gfield-choice-input" name="input_36" type="radio" value="Hotel" id="choice_8_36_0" onchange="gformToggleRadioOther( this )">
<label for="choice_8_36_0" id="label_8_36_0" class="gform-field-label gform-field-label--type-inline">Hotel</label>
</div>
<div class="gchoice gchoice_8_36_1">
<input class="gfield-choice-input" name="input_36" type="radio" value="Friends/family" id="choice_8_36_1" onchange="gformToggleRadioOther( this )">
<label for="choice_8_36_1" id="label_8_36_1" class="gform-field-label gform-field-label--type-inline">Friends/family</label>
</div>
<div class="gchoice gchoice_8_36_2">
<input class="gfield-choice-input" name="input_36" type="radio" value="Other" id="choice_8_36_2" onchange="gformToggleRadioOther( this )">
<label for="choice_8_36_2" id="label_8_36_2" class="gform-field-label gform-field-label--type-inline">Other</label>
</div>
</div>
</div>
</fieldset>
<fieldset id="field_8_37" class="gfield gfield--type-radio gfield--type-choice gfield--width-half lists field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible"
data-js-reload="field_8_37">
<legend class="gfield_label gform-field-label">Travelling:</legend>
<div class="ginput_container ginput_container_radio">
<div class="gfield_radio" id="input_8_37">
<div class="gchoice gchoice_8_37_0">
<input class="gfield-choice-input" name="input_37" type="radio" value="Alone" id="choice_8_37_0" onchange="gformToggleRadioOther( this )">
<label for="choice_8_37_0" id="label_8_37_0" class="gform-field-label gform-field-label--type-inline">Alone</label>
</div>
<div class="gchoice gchoice_8_37_1">
<input class="gfield-choice-input" name="input_37" type="radio" value="With friends/family" id="choice_8_37_1" onchange="gformToggleRadioOther( this )">
<label for="choice_8_37_1" id="label_8_37_1" class="gform-field-label gform-field-label--type-inline">With friends/family</label>
</div>
<div class="gchoice gchoice_8_37_2">
<input class="gfield-choice-input" name="input_37" type="radio" value="In a group" id="choice_8_37_2" onchange="gformToggleRadioOther( this )">
<label for="choice_8_37_2" id="label_8_37_2" class="gform-field-label gform-field-label--type-inline">In a group</label>
</div>
</div>
</div>
</fieldset>
<fieldset id="field_8_38" class="gfield gfield--type-radio gfield--type-choice gfield--width-half lists field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible"
data-js-reload="field_8_38">
<legend class="gfield_label gform-field-label">Location type:</legend>
<div class="ginput_container ginput_container_radio">
<div class="gfield_radio" id="input_8_38">
<div class="gchoice gchoice_8_38_0">
<input class="gfield-choice-input" name="input_38" type="radio" value="Urban" id="choice_8_38_0" onchange="gformToggleRadioOther( this )">
<label for="choice_8_38_0" id="label_8_38_0" class="gform-field-label gform-field-label--type-inline">Urban</label>
</div>
<div class="gchoice gchoice_8_38_1">
<input class="gfield-choice-input" name="input_38" type="radio" value="Rural" id="choice_8_38_1" onchange="gformToggleRadioOther( this )">
<label for="choice_8_38_1" id="label_8_38_1" class="gform-field-label gform-field-label--type-inline">Rural</label>
</div>
<div class="gchoice gchoice_8_38_2">
<input class="gfield-choice-input" name="input_38" type="radio" value="Altitude" id="choice_8_38_2" onchange="gformToggleRadioOther( this )">
<label for="choice_8_38_2" id="label_8_38_2" class="gform-field-label gform-field-label--type-inline">Altitude</label>
</div>
</div>
</div>
</fieldset>
<fieldset id="field_8_39" class="gfield gfield--type-radio gfield--type-choice gfield--width-half lists field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible"
data-js-reload="field_8_39">
<legend class="gfield_label gform-field-label">Activity type:</legend>
<div class="ginput_container ginput_container_radio">
<div class="gfield_radio" id="input_8_39">
<div class="gchoice gchoice_8_39_0">
<input class="gfield-choice-input" name="input_39" type="radio" value="Safari" id="choice_8_39_0" onchange="gformToggleRadioOther( this )">
<label for="choice_8_39_0" id="label_8_39_0" class="gform-field-label gform-field-label--type-inline">Safari</label>
</div>
<div class="gchoice gchoice_8_39_1">
<input class="gfield-choice-input" name="input_39" type="radio" value="Adventure" id="choice_8_39_1" onchange="gformToggleRadioOther( this )">
<label for="choice_8_39_1" id="label_8_39_1" class="gform-field-label gform-field-label--type-inline">Adventure</label>
</div>
<div class="gchoice gchoice_8_39_2">
<input class="gfield-choice-input" name="input_39" type="radio" value="Other" id="choice_8_39_2" onchange="gformToggleRadioOther( this )">
<label for="choice_8_39_2" id="label_8_39_2" class="gform-field-label gform-field-label--type-inline">Other</label>
</div>
</div>
</div>
</fieldset>
<div id="field_8_40"
class="gfield gfield--type-html gfield--width-full bold-text gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible"
data-js-reload="field_8_40">Personal medical history</div>
<div id="field_8_41" class="gfield gfield--type-text gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible" data-js-reload="field_8_41"><label
class="gfield_label gform-field-label" for="input_8_41">List all chronic medical conditions that you have (eg. diabetes, heart or lung conditions)</label>
<div class="ginput_container ginput_container_text"><input name="input_41" id="input_8_41" type="text" value="" class="large" aria-invalid="false"> </div>
</div>
<div id="field_8_42" class="gfield gfield--type-text gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible" data-js-reload="field_8_42"><label
class="gfield_label gform-field-label" for="input_8_42">If you have had a serious reaction to a vaccine in the past, which vaccine was it?</label>
<div class="ginput_container ginput_container_text"><input name="input_42" id="input_8_42" type="text" value="" class="large" aria-invalid="false"> </div>
</div>
<div id="field_8_43" class="gfield gfield--type-text gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible" data-js-reload="field_8_43"><label
class="gfield_label gform-field-label" for="input_8_43">List all of your current medications (including oral contraception)</label>
<div class="ginput_container ginput_container_text"><input name="input_43" id="input_8_43" type="text" value="" class="large" aria-invalid="false"> </div>
</div>
<fieldset id="field_8_44" class="gfield gfield--type-radio gfield--type-choice gfield--width-full field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible"
data-js-reload="field_8_44">
<legend class="gfield_label gform-field-label">Untitled</legend>
<div class="ginput_container ginput_container_radio">
<div class="gfield_radio" id="input_8_44">
<div class="gchoice gchoice_8_44_0">
<input class="gfield-choice-input" name="input_44" type="radio" value="Have you recently suffered from any infection (e.g heavy cold, flu or high temperature)?" id="choice_8_44_0" onchange="gformToggleRadioOther( this )">
<label for="choice_8_44_0" id="label_8_44_0" class="gform-field-label gform-field-label--type-inline">Have you recently suffered from any infection (e.g heavy cold, flu or high temperature)?</label>
</div>
</div>
</div>
</fieldset>
<fieldset id="field_8_45" class="gfield gfield--type-radio gfield--type-choice gfield--width-full field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible"
data-js-reload="field_8_45">
<legend class="gfield_label gform-field-label">Untitled</legend>
<div class="ginput_container ginput_container_radio">
<div class="gfield_radio" id="input_8_45">
<div class="gchoice gchoice_8_45_0">
<input class="gfield-choice-input" name="input_45" type="radio" value="Does having an injection cause you to feel faint?" id="choice_8_45_0" onchange="gformToggleRadioOther( this )">
<label for="choice_8_45_0" id="label_8_45_0" class="gform-field-label gform-field-label--type-inline">Does having an injection cause you to feel faint?</label>
</div>
</div>
</div>
</fieldset>
<fieldset id="field_8_46" class="gfield gfield--type-radio gfield--type-choice gfield--width-full field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible"
data-js-reload="field_8_46">
<legend class="gfield_label gform-field-label">Untitled</legend>
<div class="ginput_container ginput_container_radio">
<div class="gfield_radio" id="input_8_46">
<div class="gchoice gchoice_8_46_0">
<input class="gfield-choice-input" name="input_46" type="radio" value="Do you or any close family members have epilepsy?" id="choice_8_46_0" onchange="gformToggleRadioOther( this )">
<label for="choice_8_46_0" id="label_8_46_0" class="gform-field-label gform-field-label--type-inline">Do you or any close family members have epilepsy?</label>
</div>
</div>
</div>
</fieldset>
<fieldset id="field_8_47" class="gfield gfield--type-radio gfield--type-choice gfield--width-full field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible"
data-js-reload="field_8_47">
<legend class="gfield_label gform-field-label">Untitled</legend>
<div class="ginput_container ginput_container_radio">
<div class="gfield_radio" id="input_8_47">
<div class="gchoice gchoice_8_47_0">
<input class="gfield-choice-input" name="input_47" type="radio" value="Do you have any history of mental illness including depression or anxiety?" id="choice_8_47_0" onchange="gformToggleRadioOther( this )">
<label for="choice_8_47_0" id="label_8_47_0" class="gform-field-label gform-field-label--type-inline">Do you have any history of mental illness including depression or anxiety?</label>
</div>
</div>
</div>
</fieldset>
<fieldset id="field_8_48" class="gfield gfield--type-radio gfield--type-choice gfield--width-full field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible"
data-js-reload="field_8_48">
<legend class="gfield_label gform-field-label">Untitled</legend>
<div class="ginput_container ginput_container_radio">
<div class="gfield_radio" id="input_8_48">
<div class="gchoice gchoice_8_48_0">
<input class="gfield-choice-input" name="input_48" type="radio" value="Have you recently undergone radiotherapy, chemotherapy or steroid treatment?" id="choice_8_48_0" onchange="gformToggleRadioOther( this )">
<label for="choice_8_48_0" id="label_8_48_0" class="gform-field-label gform-field-label--type-inline">Have you recently undergone radiotherapy, chemotherapy or steroid treatment?</label>
</div>
</div>
</div>
</fieldset>
<fieldset id="field_8_49" class="gfield gfield--type-radio gfield--type-choice gfield--width-full field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible"
data-js-reload="field_8_49">
<legend class="gfield_label gform-field-label">Untitled</legend>
<div class="ginput_container ginput_container_radio">
<div class="gfield_radio" id="input_8_49">
<div class="gchoice gchoice_8_49_0">
<input class="gfield-choice-input" name="input_49" type="radio" value="Have you taken out travel insurance?" id="choice_8_49_0" onchange="gformToggleRadioOther( this )">
<label for="choice_8_49_0" id="label_8_49_0" class="gform-field-label gform-field-label--type-inline">Have you taken out travel insurance?</label>
</div>
</div>
</div>
</fieldset>
<fieldset id="field_8_50" class="gfield gfield--type-radio gfield--type-choice gfield--width-full field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible"
data-js-reload="field_8_50">
<legend class="gfield_label gform-field-label">Untitled</legend>
<div class="ginput_container ginput_container_radio">
<div class="gfield_radio" id="input_8_50">
<div class="gchoice gchoice_8_50_0">
<input class="gfield-choice-input" name="input_50" type="radio" value="If you have a medical condition, have you told your insurance company about it?" id="choice_8_50_0" onchange="gformToggleRadioOther( this )">
<label for="choice_8_50_0" id="label_8_50_0" class="gform-field-label gform-field-label--type-inline">If you have a medical condition, have you told your insurance company about it?</label>
</div>
</div>
</div>
</fieldset>
<fieldset id="field_8_51" class="gfield gfield--type-radio gfield--type-choice gfield--width-full field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible"
data-js-reload="field_8_51">
<legend class="gfield_label gform-field-label">Untitled</legend>
<div class="ginput_container ginput_container_radio">
<div class="gfield_radio" id="input_8_51">
<div class="gchoice gchoice_8_51_0">
<input class="gfield-choice-input" name="input_51" type="radio" value="Are you pregnant, planning pregnancy or breast feeding?" id="choice_8_51_0" onchange="gformToggleRadioOther( this )">
<label for="choice_8_51_0" id="label_8_51_0" class="gform-field-label gform-field-label--type-inline">Are you pregnant, planning pregnancy or breast feeding?</label>
</div>
</div>
</div>
</fieldset>
<div id="field_8_52" class="gfield gfield--type-textarea gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible" data-js-reload="field_8_52"><label
class="gfield_label gform-field-label" for="input_8_52">Write below any further information that might be relevant</label>
<div class="ginput_container ginput_container_textarea"><textarea name="input_52" id="input_8_52" class="textarea small" aria-invalid="false" rows="10" cols="50"></textarea></div>
</div>
<div id="field_8_53"
class="gfield gfield--type-html gfield--width-full bold-text gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible"
data-js-reload="field_8_53">Have you ever had any of the following vaccinations / tablets and if so, when?</div>
<div id="field_8_54" class="gfield gfield--type-text gfield--width-third field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible" data-js-reload="field_8_54"><label
class="gfield_label gform-field-label" for="input_8_54">Tetanus</label>
<div class="ginput_container ginput_container_text"><input name="input_54" id="input_8_54" type="text" value="" class="large" aria-invalid="false"> </div>
</div>
<div id="field_8_55" class="gfield gfield--type-text gfield--width-third field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible" data-js-reload="field_8_55"><label
class="gfield_label gform-field-label" for="input_8_55">Polio</label>
<div class="ginput_container ginput_container_text"><input name="input_55" id="input_8_55" type="text" value="" class="large" aria-invalid="false"> </div>
</div>
<div id="field_8_56" class="gfield gfield--type-text gfield--width-third field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible" data-js-reload="field_8_56"><label
class="gfield_label gform-field-label" for="input_8_56">Diptheria</label>
<div class="ginput_container ginput_container_text"><input name="input_56" id="input_8_56" type="text" value="" class="large" aria-invalid="false"> </div>
</div>
<div id="field_8_57" class="gfield gfield--type-text gfield--width-third field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible" data-js-reload="field_8_57"><label
class="gfield_label gform-field-label" for="input_8_57">Typhoid</label>
<div class="ginput_container ginput_container_text"><input name="input_57" id="input_8_57" type="text" value="" class="large" aria-invalid="false"> </div>
</div>
<div id="field_8_58" class="gfield gfield--type-text gfield--width-third field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible" data-js-reload="field_8_58"><label
class="gfield_label gform-field-label" for="input_8_58">Hepatitis A</label>
<div class="ginput_container ginput_container_text"><input name="input_58" id="input_8_58" type="text" value="" class="large" aria-invalid="false"> </div>
</div>
<div id="field_8_59" class="gfield gfield--type-text gfield--width-third field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible" data-js-reload="field_8_59"><label
class="gfield_label gform-field-label" for="input_8_59">Hepatitis B</label>
<div class="ginput_container ginput_container_text"><input name="input_59" id="input_8_59" type="text" value="" class="large" aria-invalid="false"> </div>
</div>
<div id="field_8_60" class="gfield gfield--type-text gfield--width-third field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible" data-js-reload="field_8_60"><label
class="gfield_label gform-field-label" for="input_8_60">Meningitis</label>
<div class="ginput_container ginput_container_text"><input name="input_60" id="input_8_60" type="text" value="" class="large" aria-invalid="false"> </div>
</div>
<div id="field_8_61" class="gfield gfield--type-text gfield--width-third field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible" data-js-reload="field_8_61"><label
class="gfield_label gform-field-label" for="input_8_61">Yellow Fever</label>
<div class="ginput_container ginput_container_text"><input name="input_61" id="input_8_61" type="text" value="" class="large" aria-invalid="false"> </div>
</div>
<div id="field_8_62" class="gfield gfield--type-text gfield--width-third field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible" data-js-reload="field_8_62"><label
class="gfield_label gform-field-label" for="input_8_62">Influenza</label>
<div class="ginput_container ginput_container_text"><input name="input_62" id="input_8_62" type="text" value="" class="large" aria-invalid="false"> </div>
</div>
<div id="field_8_63" class="gfield gfield--type-text gfield--width-third field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible" data-js-reload="field_8_63"><label
class="gfield_label gform-field-label" for="input_8_63">Rabies</label>
<div class="ginput_container ginput_container_text"><input name="input_63" id="input_8_63" type="text" value="" class="large" aria-invalid="false"> </div>
</div>
<div id="field_8_64" class="gfield gfield--type-text gfield--width-third field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible" data-js-reload="field_8_64"><label
class="gfield_label gform-field-label" for="input_8_64">Jap B Enceph</label>
<div class="ginput_container ginput_container_text"><input name="input_64" id="input_8_64" type="text" value="" class="large" aria-invalid="false"> </div>
</div>
<div id="field_8_65" class="gfield gfield--type-text gfield--width-third field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible" data-js-reload="field_8_65"><label
class="gfield_label gform-field-label" for="input_8_65">Tick Borne</label>
<div class="ginput_container ginput_container_text"><input name="input_65" id="input_8_65" type="text" value="" class="large" aria-invalid="false"> </div>
</div>
<div id="field_8_66" class="gfield gfield--type-text gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible" data-js-reload="field_8_66"><label
class="gfield_label gform-field-label" for="input_8_66">Malaria tablets</label>
<div class="ginput_container ginput_container_text"><input name="input_66" id="input_8_66" type="text" value="" class="large" aria-invalid="false"> </div>
</div>
<div id="field_8_67" class="gfield gfield--type-text gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible" data-js-reload="field_8_67"><label
class="gfield_label gform-field-label" for="input_8_67">Other</label>
<div class="ginput_container ginput_container_text"><input name="input_67" id="input_8_67" type="text" value="" class="large" aria-invalid="false"> </div>
</div>
</div>
</div>
<div class="gform_footer top_label"> <input type="submit" id="gform_submit_button_8" class="gform_button button" value="Submit"
onclick="if(window["gf_submitting_8"]){return false;} if( !jQuery("#gform_8")[0].checkValidity || jQuery("#gform_8")[0].checkValidity()){window["gf_submitting_8"]=true;} "
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<input type="hidden" class="gform_hidden" name="is_submit_8" value="1">
<input type="hidden" class="gform_hidden" name="gform_submit" value="8">
<input type="hidden" class="gform_hidden" name="gform_unique_id" value="">
<input type="hidden" class="gform_hidden" name="state_8"
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<input type="hidden" name="gform_field_values" value="">
</div>
</form>POST /
<form method="post" enctype="multipart/form-data" id="gform_7" action="/" data-formid="7" novalidate="">
<div class="gform-body gform_body">
<div id="gform_fields_7" class="gform_fields top_label form_sublabel_below description_below validation_below">
<div id="field_7_1" class="gfield gfield--type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible"
data-js-reload="field_7_1">
<div class="frm-title">Your Accessibility Needs</div>
<div class="frm-desc">We want to get better at communicating with our patients. We want to make sure you can read and understand the information we send you. If you find it hard to read our letters or if you need someone to support you at
appointments, please let us know.</div>
</div>
<div id="field_7_3"
class="gfield gfield--type-html gfield--width-full bold-text gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible"
data-js-reload="field_7_3">Your Details</div>
<div id="field_7_4" class="gfield gfield--type-select gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible" data-js-reload="field_7_4"><label
class="gfield_label gform-field-label" for="input_7_4">Title</label>
<div class="ginput_container ginput_container_select"><select name="input_4" id="input_7_4" class="large gfield_select" aria-invalid="false">
<option value="Mr.">Mr.</option>
<option value="Mrs.">Mrs.</option>
<option value="Miss.">Miss.</option>
<option value="Ms.">Ms.</option>
</select></div>
</div>
<div id="field_7_5"
class="gfield gfield--type-date gfield--input-type-datepicker gfield--datepicker-default-icon gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible"
data-js-reload="field_7_5"><label class="gfield_label gform-field-label" for="input_7_5">Date Of Birth<span class="gfield_required"><span class="gfield_required gfield_required_text">(Required)</span></span></label>
<div class="ginput_container ginput_container_date">
<input name="input_5" id="input_7_5" type="text" value="" class="datepicker gform-datepicker dmy datepicker_with_icon gdatepicker_with_icon hasDatepicker initialized" placeholder="dd/mm/yyyy" aria-describedby="input_7_5_date_format"
aria-invalid="false" aria-required="true"><img class="ui-datepicker-trigger" src="https://nhsgp.net/wp-content/plugins/gravityforms/images/datepicker/datepicker.svg" alt="Select date" title="Select date">
<span id="input_7_5_date_format" class="screen-reader-text">DD slash MM slash YYYY</span>
</div>
<input type="hidden" id="gforms_calendar_icon_input_7_5" class="gform_hidden" value="https://nhsgp.net/wp-content/plugins/gravityforms/images/datepicker/datepicker.svg">
</div>
<div id="field_7_8" class="gfield gfield--type-text gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible" data-js-reload="field_7_8">
<label class="gfield_label gform-field-label" for="input_7_8">First name:<span class="gfield_required"><span class="gfield_required gfield_required_text">(Required)</span></span></label>
<div class="ginput_container ginput_container_text"><input name="input_8" id="input_7_8" type="text" value="" class="large" aria-required="true" aria-invalid="false"> </div>
</div>
<div id="field_7_9" class="gfield gfield--type-text gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible" data-js-reload="field_7_9">
<label class="gfield_label gform-field-label" for="input_7_9">Surname:<span class="gfield_required"><span class="gfield_required gfield_required_text">(Required)</span></span></label>
<div class="ginput_container ginput_container_text"><input name="input_9" id="input_7_9" type="text" value="" class="large" aria-required="true" aria-invalid="false"> </div>
</div>
<div id="field_7_10" class="gfield gfield--type-textarea gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible"
data-js-reload="field_7_10"><label class="gfield_label gform-field-label" for="input_7_10">Home address:<span class="gfield_required"><span class="gfield_required gfield_required_text">(Required)</span></span></label>
<div class="ginput_container ginput_container_textarea"><textarea name="input_10" id="input_7_10" class="textarea small" aria-required="true" aria-invalid="false" rows="10" cols="50"></textarea></div>
</div>
<div id="field_7_11" class="gfield gfield--type-text gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible" data-js-reload="field_7_11">
<label class="gfield_label gform-field-label" for="input_7_11">Postcode:<span class="gfield_required"><span class="gfield_required gfield_required_text">(Required)</span></span></label>
<div class="ginput_container ginput_container_text"><input name="input_11" id="input_7_11" type="text" value="" class="large" aria-required="true" aria-invalid="false"> </div>
</div>
<div id="field_7_14" class="gfield gfield--type-phone gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible" data-js-reload="field_7_14">
<label class="gfield_label gform-field-label" for="input_7_14">Home tel:<span class="gfield_required"><span class="gfield_required gfield_required_text">(Required)</span></span></label>
<div class="ginput_container ginput_container_phone"><input name="input_14" id="input_7_14" type="tel" value="" class="large" aria-required="true" aria-invalid="false"></div>
</div>
<div id="field_7_13" class="gfield gfield--type-textarea gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible" data-js-reload="field_7_13"><label
class="gfield_label gform-field-label" for="input_7_13">Please tell us what communication requirements you have (eg. braile, large print, etc)</label>
<div class="ginput_container ginput_container_textarea"><textarea name="input_13" id="input_7_13" class="textarea small" aria-invalid="false" rows="10" cols="50"></textarea></div>
</div>
</div>
</div>
<div class="gform_footer top_label"> <input type="submit" id="gform_submit_button_7" class="gform_button button" value="Submit"
onclick="if(window["gf_submitting_7"]){return false;} if( !jQuery("#gform_7")[0].checkValidity || jQuery("#gform_7")[0].checkValidity()){window["gf_submitting_7"]=true;} "
onkeypress="if( event.keyCode == 13 ){ if(window["gf_submitting_7"]){return false;} if( !jQuery("#gform_7")[0].checkValidity || jQuery("#gform_7")[0].checkValidity()){window["gf_submitting_7"]=true;} jQuery("#gform_7").trigger("submit",[true]); }">
<input type="hidden" class="gform_hidden" name="is_submit_7" value="1">
<input type="hidden" class="gform_hidden" name="gform_submit" value="7">
<input type="hidden" class="gform_hidden" name="gform_unique_id" value="">
<input type="hidden" class="gform_hidden" name="state_7" value="WyJbXSIsIjIyZDg5ZTVjZWRhYTEzY2EyMjdhNzkzNTllOWFkYTUxIl0=">
<input type="hidden" class="gform_hidden" name="gform_target_page_number_7" id="gform_target_page_number_7" value="0">
<input type="hidden" class="gform_hidden" name="gform_source_page_number_7" id="gform_source_page_number_7" value="1">
<input type="hidden" name="gform_field_values" value="">
</div>
</form>POST /
<form method="post" enctype="multipart/form-data" id="gform_16" action="/" data-formid="16" novalidate="">
<div class="gform-body gform_body">
<div id="gform_fields_16" class="gform_fields top_label form_sublabel_below description_below validation_below">
<div id="field_16_1" class="gfield gfield--type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible"
data-js-reload="field_16_1">
<div class="frm-title">Requesting Fit Note (Med3)</div>
<div class="frm-desc">The more information you put in this form, the more opportunity we have to help you with your Fit note request</div>
</div>
<div id="field_16_3"
class="gfield gfield--type-html gfield--width-full bold-text gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible"
data-js-reload="field_16_3">Your details: </div>
<div id="field_16_4" class="gfield gfield--type-select gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible" data-js-reload="field_16_4"><label
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<option value="Mr.">Mr.</option>
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<option value="Ms.">Ms.</option>
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data-js-reload="field_16_5"><label class="gfield_label gform-field-label" for="input_16_5">Date of birth:<span class="gfield_required"><span class="gfield_required gfield_required_text">(Required)</span></span></label>
<div class="ginput_container ginput_container_date">
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<label class="gfield_label gform-field-label" for="input_16_6">First name:<span class="gfield_required"><span class="gfield_required gfield_required_text">(Required)</span></span></label>
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<label class="gfield_label gform-field-label" for="input_16_7">Surname:<span class="gfield_required"><span class="gfield_required gfield_required_text">(Required)</span></span></label>
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data-js-reload="field_16_10"><label class="gfield_label gform-field-label" for="input_16_10">Telephone:<span class="gfield_required"><span class="gfield_required gfield_required_text">(Required)</span></span></label>
<div class="ginput_container ginput_container_phone"><input name="input_10" id="input_16_10" type="tel" value="" class="large" aria-required="true" aria-invalid="false"></div>
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<div id="field_16_11"
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data-js-reload="field_16_11">The next part of this form, is you opportunity to clarify why you are asking for a fit note.</div>
<div id="field_16_12" class="gfield gfield--type-text gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible"
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class="gfield_required gfield_required_text">(Required)</span></span></label>
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class="gfield gfield--type-date gfield--input-type-datepicker gfield--datepicker-default-icon gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible"
data-js-reload="field_16_13"><label class="gfield_label gform-field-label" for="input_16_13">Proposed Fit Note Start Date<span class="gfield_required"><span class="gfield_required gfield_required_text">(Required)</span></span></label>
<div class="ginput_container ginput_container_date">
<input name="input_13" id="input_16_13" type="text" value="" class="datepicker gform-datepicker dmy datepicker_with_icon gdatepicker_with_icon hasDatepicker initialized" placeholder="dd/mm/yyyy" aria-describedby="input_16_13_date_format"
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<span id="input_16_13_date_format" class="screen-reader-text">DD slash MM slash YYYY</span>
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<input type="hidden" id="gforms_calendar_icon_input_16_13" class="gform_hidden" value="https://nhsgp.net/wp-content/plugins/gravityforms/images/datepicker/datepicker.svg">
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data-js-reload="field_16_14"><label class="gfield_label gform-field-label" for="input_16_14">Proposed Fit Note End Date<span class="gfield_required"><span class="gfield_required gfield_required_text">(Required)</span></span></label>
<div class="ginput_container ginput_container_date">
<input name="input_14" id="input_16_14" type="text" value="" class="datepicker gform-datepicker dmy datepicker_with_icon gdatepicker_with_icon hasDatepicker initialized" placeholder="dd/mm/yyyy" aria-describedby="input_16_14_date_format"
aria-invalid="false" aria-required="true"><img class="ui-datepicker-trigger" src="https://nhsgp.net/wp-content/plugins/gravityforms/images/datepicker/datepicker.svg" alt="Select date" title="Select date">
<span id="input_16_14_date_format" class="screen-reader-text">DD slash MM slash YYYY</span>
</div>
<input type="hidden" id="gforms_calendar_icon_input_16_14" class="gform_hidden" value="https://nhsgp.net/wp-content/plugins/gravityforms/images/datepicker/datepicker.svg">
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<div id="field_16_15" class="gfield gfield--type-text gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible"
data-js-reload="field_16_15"><label class="gfield_label gform-field-label" for="input_16_15">Why do you feel that your medical condition stops you from working?<span class="gfield_required"><span
class="gfield_required gfield_required_text">(Required)</span></span></label>
<div class="ginput_container ginput_container_text"><input name="input_15" id="input_16_15" type="text" value="" class="large" aria-required="true" aria-invalid="false"> </div>
</div>
<div id="field_16_16" class="gfield gfield--type-text gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible"
data-js-reload="field_16_16"><label class="gfield_label gform-field-label" for="input_16_16">What investigations/treatment have you been doing/taking for the above medical condition?<span class="gfield_required"><span
class="gfield_required gfield_required_text">(Required)</span></span></label>
<div class="ginput_container ginput_container_text"><input name="input_16" id="input_16_16" type="text" value="" class="large" aria-required="true" aria-invalid="false"> </div>
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<div id="field_16_17" class="gfield gfield--type-text gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible"
data-js-reload="field_16_17"><label class="gfield_label gform-field-label" for="input_16_17">What evidence do you have from your specialist specifying that you cannot work?<span class="gfield_required"><span
class="gfield_required gfield_required_text">(Required)</span></span></label>
<div class="ginput_container ginput_container_text"><input name="input_17" id="input_16_17" type="text" value="" class="large" aria-required="true" aria-invalid="false"> </div>
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<div id="field_16_18"
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data-js-reload="field_16_18">Please email any supporting documents to docman.e84066@nhs.net</div>
<div id="field_16_19" class="gfield gfield--type-captcha gfield--width-full field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible" data-js-reload="field_16_19"><label
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GP Pathfinder Clinics
at Hazeldene Medical Centre,
Crest, Eagle Eye and
Chamberlayne Road Surgery
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appropriate medical assistance for you, with just a few clicks.
With our online GP services, you can arrange everything from a GP video
consultation to ongoing appointments or prescriptions at your local GP practice
in North London. We have practises in Wembley, Willesden, Alperton and Queen’s
Park linked to our remote portal. You will also get access to a range of health
management tools to use at your convenience.
If you have questions about the online GP registration, get in touch today to
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PLEASE HAVE A LOOK AT OUR VIDEOS FOR MORE INFORMATION ON THE MEDICAL CENTRE AND
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Our clinic locations
(more opening soon!)
* Alperton 26 Eagle Road Wembley HAO 4SH United Kingdom
Phone: 020 8902 8223
0.4 mi Directions
* Wembley 1b Wyld Way Wembley HA9 6PW United Kingdom
Phone: 020 8902 4792
1.2 mi Directions
* Willesden 157 Crest Road London NW2 7 United Kingdom
Phone: 020 8452 5155
3.3 mi Directions
* Queen’s Park 124 Chamberlayne Road London NW10 3JP United Kingdom
Phone: 020 8206 6590
3.4 mi Directions
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NHS GP Hazeldene Medical Centre
3.7
Based on 781 reviews
review us on
Daniel
vor einem Jahr
I had an amazing experience at this practice. The whole team was so welcoming
and helpful throughout! It was also really inspiring to see everyone
consistently go the extra mile for their patients and make sure they have well
looked after.
Juanitas Jone
vor einem Jahr
They provided excellent patient care and exceptional service. Compassionate
friendly and welcoming doctors and nurses and staff members including
receptionists who go out of their way to book and manage prompt appointments. I
have never felt more cared for. I highly recommend NHS GP Hazeldene Medical
Centre!
Bhavesh Sodha
vor 2 Jahren
A special thanks to Dr Bhavini Patel who I met today with my mother. She is
knowledgeable and knows what she is doing. She calmly listened to our
doubts/questions and advised accordingly. Nurses, receptionists and other
doctors are helpful too. Great location. Great service.
CLINIC OPENING HOURS
* Monday 8am–6.30pm
* Tuesday 8am–6.30pm
* Wednesday 8am–6.30pm
* Thursday 8am–6.30pm
* Friday 8am–6.30pm
* Saturday Closed
* Sunday Closed
Hazeldene Medical Centre
CQC overall rating
Good
16 October 2019
See the report
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ALPERTON
The Eagle Eye Surgery
26 Eagle Road
HAO 4SH
Phone: 020 8902 8223
QUEEN’S PARK
Chamberlayne Rd Surgery
124 Chamberlayne Road
NW10 3JP
Phone: 020 8206 6590
WILLESDEN
Crest Medical Centre
157 Crest Road
NW2 7
Phone: 020 8452 5155
WEMBLEY
Hazeldene Medical Centre
1b Wyld Way
HA9 6PW
Phone: 020 8902 4792
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CHANGE OF CONTACT DETAILS
Change of Contact Details
Title(Required)
MrMrsMissMsDrProf
First Name(s)(Required)
Surname:(Required)
Sex(Required)
Female
Male
Date of Birth
DD slash MM slash YYYY
Previous Surname
NHS No
Email:(Required)
Old Address
Old Postcode(Required)
Old Home Tel(Required)
New Address(Required)
New Postcode
New Tel(Required)
Mobile
Work Tel
Are you a student?(Required)
I am NOT a student
I AM a student
Other members of your family requiring a change of address (if registered here)
COMMENTS AND SUGGESTIONS FORM
Comments and Suggestions Form
This is the easiest way to make a complaint or leave a comment for us.
WHAT KIND OF COMMENT WOULD YOU LIKE TO SEND? REMEMBER THIS FORM IS NOT FOR
MEDICAL MATTERS.
Your comment is:
A suggestion
Praise
Regarding a problem
Other
What would you like to say? Enter your comments in the space below
YOUR CONTACT DETAILS
Your name:
Your email:
Your telephone number:
Do you agree to be contacted regarding this matter?(Required)
Yes, I agree that the practice may contact me regarding this matter
SICK NOTE REQUEST FORM
Requesting Fit Note (Med3)
The more information you put in this form, the more opportunity we have to help
you with your Fit note request
Your details:
Title:
Mr.Mrs.Miss.Ms.
Date of birth:(Required)
DD slash MM slash YYYY
First name:(Required)
Surname:(Required)
Email:(Required)
Postcode:(Required)
Telephone:(Required)
The next part of this form, is you opportunity to clarify why you are asking for
a fit note.
Medical reason for sick note request:(Required)
Proposed Fit Note Start Date(Required)
DD slash MM slash YYYY
Proposed Fit Note End Date(Required)
DD slash MM slash YYYY
Why do you feel that your medical condition stops you from working?(Required)
What investigations/treatment have you been doing/taking for the above medical
condition?(Required)
What evidence do you have from your specialist specifying that you cannot
work?(Required)
Please email any supporting documents to docman.e84066@nhs.net
CAPTCHA
PERSONAL QUIT PLAN
QUIT SMOKING WITH YOUR FREE PERSONAL QUIT PLAN
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combination that's right for you in 4 easy steps.
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ALCOHOL QUESTIONNAIRE FOR ADULTS
This is the easiest way to make a complaint or leave a comment for us.
Alcohol Questionnaire for Adults
This is the easiest way to make a complaint or leave a comment for us.
Your contact details
Title:
Mr.Mrs.Miss.Ms.
First name:(Required)
Last name:(Required)
Date of birth:(Required)
DD slash MM slash YYYY
Email(Required)
Home phone:(Required)
Work phone:(Required)
Mobile phone:(Required)
Home address:(Required)
Alcohol
How often do you have a drink containing alcohol?
NeverMonthky Or Less2-4 times a month2-3 times a week4 or more times a week
How many standard drinks containing alcohol do you have on a typical day?
1 or 23 or 45 or 67 or 810 or more
MEN: How often do you have EIGHT or more drinks on one occasion?
NeverLess than MonthlyMonthlyWeeklyDaily
WOMEN: How often do you have SIX or more drinks on one occasion?
NeverLess than MonthlyMonthlyWeeklyDaily
1 drink = 1/2 pint of beer or 1 glass of wine or 1 single spirits.
1 unit of alcohol = 10cc of alcohol. So, a small glass (125cc) of 12% wine is
12.5 * 0.12 = 1.5 units.
APPLICATION TO REGISTER WITH A GENERAL MEDICAL PRACTITIONER
Application to Register with a General Medical Practitioner
PATIENT'S DETAILS
Please complete the text boxes and tick where appropriate
Title:
Mr.Mrs.Miss.Ms.
Surname:(Required)
Previous surname:
First Name(s):(Required)
Birth country:(Required)
Birth town:(Required)
Home address:(Required)
Postcode:(Required)
Telephone:(Required)
Date of birth:(Required)
DD slash MM slash YYYY
NHS Number:
Sex:
Male
Female
I am a student at:
PATIENT'S DETAILS
Your previous address:
Name and address of previous GP while at previous address:
IF YOU ARE FROM ABROAD
Your first UK address where registered with a GP:
If previously resident in UK, date of leaving
MM slash DD slash YYYY
Date you first came to live in UK
MM slash DD slash YYYY
IF YOU ARE RETURNING FROM THE ARMED FORCES
Address before enlisting:
Service/Personnel No.
Enlistment date:
DD slash MM slash YYYY
If you are registering a child under 5
I wish the child above to be registered with the named doctor for Child Health
Surveillance
If you need your doctor to dispense medicines and appliances
I live more than 1 mile in a straight line from the nearest chemist
I would have serious difficulty in getting them from a chemist
Signature of patient
Signature on behalf of patient
Date:
DD slash MM slash YYYY
NHS ORGAN DONOR REGISTRATION
I want to register my details on the NHS Organ Donor Register as someone whose
organs/tissue may be used for transplantation after my death. Please tick the
boxes that apply:
Any of my organs or
Kidneys
Heart
Liver
Corneas
Lungs
Pancreas
Any part of my body
NHS BLOOD DONOR REGISTRATION
I would like to join the NHS Blood Donor Register as someone who may be
contacted and would be prepared to donate blood.
Tick here if you have given blood in the last 3 years
Tick here if you have given blood in the last 3 years
For more information, please ask for the leaflet on joining the NHS Blood Donor
Register Preferred address for donation: (if different from above, e.g. place of
work)
Postcode:
SUPPLEMENTARY QUESTIONS
PATIENT DECLARATION FOR ALL PATIENTS WHO ARE NOT ORDINARILY RESIDENT IN THE UK
Anybody in England can register with a GP practice and receive free medical care
from that practice. However, if you are not 'ordinarily resident' in the UK you
may have to pay for NHS treatment outside of the GP practice. Being ordinarily
resident broadly means living lawfully in the UK on a properly settled basis for
the time being. In most cases, nationals of countries outside the European
Economic Area must also have the status of 'indefinite leave to remain' in the
UK. Some services, such as diagnostic tests of suspected infectious diseases and
any treatment of those diseases are free of charge to all people, while some
groups who are not ordinarily resident here are exempt from all treatment
charges. More information on ordinary residence, exemptions and paying for NHS
services can be found in the Visitor and Migrant patient leaflet, available from
your GP practice. You may be asked to provide proof of entitlement in order to
receive free NHS treatment outside of the GP practice, otherwise you may be
charged for your treatment. Even if you have to pay for a service, you will
always be provided with any immediately necessary or urgent treatment,
regardless of advance payment. The information you give on this form will be
used to assist in identifying your chargeable status, and may be shared,
including with NHS secondary care organisations (e.g. hospitals) and NHS
Digital, for the purposes of validation, invoicing and cost recovery. You may be
contacted on behalf of the NHS to confirm any details you have provided.
COMPLETE THIS SECTION IF YOU LIVE IN ANOTHER EEA COUNTRY, OR HAVE MOVED TO THE
UK TO STUDY OR RETIRE, OR IF YOU LIVE IN THE UK BUT WORK IN ANOTHER EEA MEMBER
STATE. DO NOT COMPLETE THIS SECTION IF YOU HAVE AN EHIC ISSUED BY THE UK.
Please tick one of the following boxes:
I understand that I may need to pay for NHS treatment outside of the GP practice
I understand I have a valid exemption from paying for NHS treatment outside of
the GP practice. This includes for example, an EHIC, or payment of the
Immigration Health Charge ('the Surcharge'), when accompanied by a valid visa. I
can provide documents to support this when requested
I do not know my chargeable status
I declare that the information I give on this form is correct and complete. I
understand that if it is not correct, appropriate action may be taken against
me.(Required)
Are you a parent or guardian, filling out this form on behalf of a child under
16?
Name parent or guardian:
Relationship to patient:
NON-UK EUROPEAN HEALTH INSURANCE CARD (EHIC), PROVISIONAL REPLACEMENT
CERTIFICATE (PRC) DETAILS AND S1 FORMS
IF YOU ARE VISITING FROM ANOTHER EEA COUNTRY AND DO NOT HOLD A CURRENT EHIC (OR
PROVISIONAL REPLACEMENT CERTIFICATE (PRC)/S1, YOU MAY BE BILLED FOR THE COST OF
ANY TREATMENT RECEIVED OUTSIDE THE GP PRACTICE, INCLUDING AT HOSPITAL).
Do you have a non-UK EHIC or PRC?
Yes
No
If yes, please enter details from your EHIC or PRC below:
Name:
Given names:
Date of birth:
DD slash MM slash YYYY
Personal Identification Number:
Country code:
Expiry date:
DD slash MM slash YYYY
Identification number of the institution:
Identification number of the card:
PRC validity period
From:
DD slash MM slash YYYY
To:
DD slash MM slash YYYY
Untitled(Required)
Please tick if you have an S1 (e.g. you are retiring to the UK or you have been
posted here by your employer for work or you live in the UK but work in another
EEA member state) Please give your S1 form to the practice staff.
How will your EHIC/PRC/S1 data be used? By using your EHIC or PRC for NHS
treatment costs your EHIC or PRC data and GP appointment data will be shared
with NHS secondary care (hospitals) and NHS Digital solely for the purposes of
cost recovery. Your clinical data will not be shared in the cost recovery
process. Your EHIC, PRC or S1 information will be shared with The Department for
Work and Pensions for the purpose of recovering your NHS costs from your home
country.
ARE YOU A CARER?
Do you look after a family member or friend who is unwell, disabled or frail?
Are You A Carer?
Do you look after a family member or friend who is unwell, disabled or frail?
If so please complete this form. Once you are added to our list of carers we
will know about your busy life as a carer, which can affect your health. We can
also try and be flexible with appointments etc as we will know about your
commitments.
Carer details
Title:
Mr.Mrs.Miss.Ms.
First name:(Required)
Last name(s):(Required)
Address:(Required)
Postcode:
Date of birth:(Required)
DD slash MM slash YYYY
Telephone:(Required)
Email
Details of Person Being Cared For
Title:
Mr.Mrs.Miss.Ms.
First name:
Last name(s):
Address:
Postcode:
Date of birth:
DD slash MM slash YYYY
What relation is the person you care for?
Is the person you care for a patient at NHS GP?
Yes
No
ASTHMA ANNUAL REVIEW QUESTIONNAIRE
Asthma Annual Review Questionnaire
CONTACT DETAILS
Name:(Required)
Date of birth:(Required)
DD slash MM slash YYYY
Home phone:(Required)
Mobile phone:(Required)
Email:(Required)
Postcode
Home address:(Required)
Questionnaire
1. When was your asthma diagnosed?
Less than 5 years agoMore than 5 years agoLess than 10 years ago
2. In the last month, have you had any difficulty sleeping because of your
asthma symptoms (including cough)?
NoYes, every dayYes, 1-2 times a weekYes, 1-2 times a monthYes, 1-2 times a
yearYes, see below for details
Details of sleeping difficulties:
3. In the last month, have you had your usual asthma symptoms during the day?
(cough, wheeze, chest tightness or breathlessness)?
NoYes, every dayYes, 1-2 times a weekYes, 1-2 times a monthYes, 1-2 times a
yearYes, see below for details
Details of symptoms during the day:
4. How often do you use your blue inhaler?
DailyWeeklyMonthlyYearlyOther, see below for details
Details of inhaler use:
5. In the last month has your asthma interfered with your usual activities (e.g.
housework, work, school etc)?
Yes
No
6. Have you ever had your peak flow measured at the surgery?
Yes
No
If yes, do you know your best PEFR value
7. Are you happy with your inhaler technique?
Yes
No
If you are not, did you know there is an online demonstration on the Asthma UK
website or you could pop in and see our practice nurse for more advice.
8. Have you ever smoked?
Yes
No
If 'Yes', please answer the following:
Do you smoke now?
Yes
No
If 'Yes' how many do you smoke each day?
If 'No' when did you quit?
There are plenty of options available to help you quit. Is this something you
would like us to contact you about?
Yes
No
CHANGE OF CONTACT DETAILS
Change of Contact Details
Title(Required)
MrMrsMissMsDrProf
First Name(s)(Required)
Surname:(Required)
Sex(Required)
Female
Male
Date of Birth
DD slash MM slash YYYY
Previous Surname
NHS No
Email:(Required)
Old Address
Old Postcode(Required)
Old Home Tel(Required)
New Address(Required)
New Postcode
New Tel(Required)
Mobile
Work Tel
Are you a student?(Required)
I am NOT a student
I AM a student
Other members of your family requiring a change of address (if registered here)
COMMENTS AND SUGGESTIONS FORM
Comments and Suggestions Form
This is the easiest way to make a complaint or leave a comment for us.
WHAT KIND OF COMMENT WOULD YOU LIKE TO SEND? REMEMBER THIS FORM IS NOT FOR
MEDICAL MATTERS.
Your comment is:
A suggestion
Praise
Regarding a problem
Other
What would you like to say? Enter your comments in the space below
YOUR CONTACT DETAILS
Your name:
Your email:
Your telephone number:
Do you agree to be contacted regarding this matter?(Required)
Yes, I agree that the practice may contact me regarding this matter
Advice in your region
England | Scotland | Wales | Northern Ireland | Ireland
Get the latest NHS information and advice about coronavirus (COVID-19).
Check if you or your child has coronavirus symptoms
Find out about the main symptoms of coronavirus and what to do if you have them.
Self-isolation and treatment if you have coronavirus symptoms
Advice about staying at home (self-isolation) and treatment for you and anyone
you live with.
Testing and tracing
Information about testing for coronavirus and what to do if you're contacted by
the NHS Test and Trace service.
People at high risk
Advice for people at higher risk from coronavirus, including older people,
people with health conditions and pregnant women.
Social distancing and changes to everyday life
Advice about avoiding close contact with other people (social distancing),
looking after your wellbeing and using the NHS and other services during
coronavirus.
GOV.UK: coronavirus – guidance and support
Government information and advice.
NEW PATIENT HEALTH QUESTIONNAIRE FOR ADULTS
New Patient Health Questionnaire for Adults
YOUR CONTACT DETAILS
Title:
Mr.
Mrs.
Miss.
Ms.
First name:(Required)
Surname(s):(Required)
Previous surname
Occupation:
Date of birth:(Required)
DD slash MM slash YYYY
Address:(Required)
Postcode:
Email:
Telephone:(Required)
Work tel:
Mobile:
INFORMATION ABOUT YOU
What is your height?(Required)
What is your weight?(Required)
What is your first language?(Required)
Do you need an interpreter?(Required)
Yes
No
Ethnic Group
BritishIrishCaribbeanAfricanIndianPakistaniChineseWhite + Black CaribbeanWhite +
Black AfricanWhite + AsianOther
If other, please specify
PREVIOUS GP
Name and Address of Previous GP
Proof of Identity and Address Provided
Birth Certificate
Driving Licence
Passport
Utility Bill
Allowance Book
Solicitor's Letter
Offer of Tenancy
Other
MEDICAL INFORMATION
Please list any serious illnesses / operations / accidents / disabilities (and
for women any pregnancy related problems) and the year they took place:
Have you ever suffered from? (tick as appropriate)
Epilepsy
Yes
No
Heart Attack/Stroke
Yes
No
High Blood Pressure
Yes
No
Cancer
Yes
No
Eczema/Hay Fever
Yes
No
Blindness/Glaucoma
Yes
No
Diabetes
Yes
No
Depression
Yes
No
Asthma
Yes
No
COPD
Yes
No
If yes, please state the year(s) when were you first diagnosed?
Please list any medicines being taken and the amount:
Are you registered disabled?
Yes
No
If yes, please give details:
Have you ever refused treatment/screening of any kind?
Yes
No
If yes, please give details:
Are you allergic to any medicines?
Yes
No
If so, what and when?
Have you ever suffered from? (tick as appropriate)
Anxiety
Yes
No
Depression
Yes
No
OCD
Yes
No
Bipolar Disorder
Yes
No
If yes to any of these, please state the year(s) when were you first diagnosed?
Do you have any other mental health issues? (If yes please give details)
Are you receiving or have you received any treatment or therapy? (If yes please
give details of your care and when you received it)
CARERS
Do you have a carer?
Yes
No
If yes please give details:
Are you a carer?
Yes
No
If yes please give details:
WILLS
Do you hold a Living Will?
Yes
No
(A Living Will is documentation regarding your personal wishes in respect of
medical intervention at the time of serious illness)
WOMEN
Have you ever had a cervical smear?
Yes
No
If 'yes', please state when, where and the result:
SMOKING
Do you smoke?
Yes
No
If 'No', have you ever smoked?
Yes
No
Would you like advice on giving up smoking?
Yes
No
If you do currently smoke, how many cigarettes or ounces of tobacco do you smoke
per week?
ALCOHOL
1 drink = 1/2 pint of beer or 1 glass of wine or 1 single spirits
MEN: How often do you have EIGHT or more drinks on one occasion?
NeverLess than monthlyMonthlyWeeklyDaily
WOMEN: How often do you have SIX or more drinks on one occasion?
NeverLess than monthlyMonthlyWeeklyDaily
How often during the last year have you been unable to remember what happened
the night before because you had been drinking?
NeverLess than monthlyMonthlyWeeklyDaily
How often during the last year have you failed to do what was normally expected
of you because of drinking?
NeverLess than monthlyMonthlyWeeklyDaily
In the last year has a relative or friend, or a doctor or other health worker
been concerned about your drinking or suggested you cut down?
NoYes, on one occasionYes, more than once
FAMILY HISTORY
Please state any serious illness, in particular cancer, heart disease, stroke,
high blood pressure, diabetes or any inherited disease. Please state your
relationship to the individual and in the case of cancer, the type of cancer.
NEXT OF KIN
Please give name, address, telephone number and relationship of next of kin:
CONTACTING YOU
Have you had a flu vaccination? Enter date or 'never':
Have you had a pneumococcal vaccination? Enter date or 'never'
FOR PATIENTS AGED 65 AND OVER OR THOSE WITH A CHRONIC DISEASE (E.G. ASTHMA OR
DIABETES)
Untitled(Required)
I agree that I may be contacted from time to time, via email and/or SMS, with
practice news, advice about my health and/or appointment reminders.
REGISTERING WITH A GP SURGERY OUTSIDE THE AREA YOU LIVE?
You do not need to register with a GP surgery in the area you live.
Registering with a GP surgery outside the area you live?
You do not need to register with a GP surgery in the area you live.
You can register with a surgery that's more convenient, for example closer to
your work or your children's school..
The GP surgery can refuse registration for reasons such as they are not taking
new patients or it's too far away from your home and you need home visits.
Your details
Title:
Mr.Mrs.Miss.Ms.
First name:(Required)
Last name(s):(Required)
Address:(Required)
Postcode:
Date of birth:(Required)
DD slash MM slash YYYY
Mobile(Required)
Email(Required)
Reason for registering with our practice in London
Do any of the following reasons for London GP Registration apply?(Required)
I live in LondonI work in LondonI attend a University, College or educational
establishment in LondonI visit London at least once a weekI am having difficulty
registering with a GP in my area
Terms of Registering with GP far away from home.
The surgery will decide if they can accept you as a regular patient or accept
you without home visits.
Because of the distance to your home, the GP surgery might not be able to offer
home visits.
If you are not well enough to go to the GP surgery, other arrangements might be
made.
Registering with a practice further away from home can affect decisions about
referrals for hospital tests and treatment, or access to community health
services
Additionally the offer of Cancer Screen Services and practice based Blood Tests
and Investigations maybe a long distance for you to travel
Do you accept the Terms of Registering with a GP far away from home?
Do you accept the Terms of Registering with a GP far away from home?(Required)
YesNoI need more information, please call me
REPEAT PRESCRIPTION REQUEST FORM
Repeat Prescription Request Form
PATIENT 1 DETAILS
Full name:(Required)
Date of birth:(Required)
DD slash MM slash YYYY
Email:
Daytime tel:(Required)
Patient ID:(Required)
Your Doctor:
Dr Sandra ForemanDr Billy NeighbourProf Paul Lum
Collect from:
The SurgeryBierley PharmacyLloyds Pharmacy - Rooley laneBootsLloyds CultsRowland
CultsWoods, PeterculterJones Pharmacy
You may request up to twenty separate items. Enter each drug and strength on
your prescription. Untick the 'Required' box if you do not require the item this
time. Please note that items will only be dispensed if they are included on your
repeat prescription and a medication review is not pending
Drug
Untitled
Untitled
Required
Drug
Untitled
Untitled
Required
Drug
Untitled
Untitled
Required
Drug
Untitled
Untitled
Required
Drug
Untitled
Untitled
Required
Drug
Untitled
Untitled
Required
Drug
Untitled
Untitled
Required
Drug
Untitled
Untitled
Required
Drug
Untitled
Untitled
Required
Drug
Untitled
Untitled
Required
Drug
Untitled
Untitled
Required
Drug
Untitled
Untitled
Required
Please do not include medical problems here - these should be discussed with
your doctor
REQUEST TO REGISTER FOR ONLINE SERVICES
Request to Register for Online Services
Your details
First name:(Required)
Last name:(Required)
Date of birth:(Required)
DD slash MM slash YYYY
Postcode:
Home tel::(Required)
Mobile:
Email
SIGNING UP FOR PATIENT REFERENCE GROUP
Signing Up For Patient Reference Group
If you are happy for us to contact you periodically by email please fill out all
the fields below and send the completed form to us.
Your details
Title:
Mr.Mrs.Miss.Ms.
Date of birth:(Required)
DD slash MM slash YYYY
First name:(Required)
Surname:(Required)
Email:(Required)
Postcode:(Required)
Telephone:(Required)
The information below will help to make sure that we receive feedback from a
representative sample of the patients registered at this practice.
Your Gender
Male
Female
Your Age
Under 16
17-24
25-34
35-44
45-54
55-64
65-74
75-84
Over 84
The ethnic background with which you most closely identify is:
British Group
Irish
White & Black Caribbean
White & Black African
White & Asian
Indian
Pakistani
Bangladeshi
Caribbean
African
Chinese
Any other
How would you describe how often you come to the practice?
Regularly
Occasionally
Very Rarely
THE GENERAL PRACTICE ASSESSMENT QUESTIONNAIRE (GPAQ)
The General Practice Assessment Questionnaire (GPAQ)
Firstly, please tell us the name of your usual doctor
Dr Jahan MahmoodiDr Vruti PatelDr Sarah ElhagDr Bhavini PatelDr Kanishka
SamarasingheDr Marie WilsonDr Furquan TaherDr Ishani PatelDr Kamal Patel
1. In the past 12 months, how many times have you seen a doctor from your
practice?
NoneOnce or twiceThree or four timesFive or six timesSeven times or more
2. How do you rate the way you are treated by receptionists at your practice?
Very poorPoorFairGoodVery goodExcellent
3 a) How do you rate the hours that your practice is open for appointments?
Very poorPoorFairGoodVery goodExcellent
3 b) What additional hours would you like the practice to be open? (please tick
all that apply)
Early morning
Good
Evenings
Weekends
None, I am satisfied
4 a) Thinking of times when you want to see a particular doctor, how quickly do
you usually get to see that doctor?
Same dayNext working dayWithin 2 working daysWithin 3 working daysWithin 4
working days5 or more working daysDoes not apply
4 b) How do you rate this?
Very poorPoorFairGoodVery goodExcellentDoes not apply
5 a) Thinking of times when you are willing to see any doctor, how quickly do
you usually get seen?
Same dayNext working dayWithin 2 working daysWithin 3 working daysWithin 4
working days5 or more working daysDoes not apply
5 b) How do you rate this?
Very poorPoorFairGoodVery goodExcellentDoes not apply
6. If you need to see a GP urgently, can you normally get seen on the same day?
YesNoDon't know/Never needed to
7. a) How long do you usually have to wait at the practice for your
consultations to begin?
5 minutes or less6-10 minutes11-20 minutes21-30 minutesMore than 30 minutes
7 b) How do rate this?
Very poorPoorFairGoodVery goodExcellent
8 a) Thinking of times you have phoned the practice, how do you rate the ability
to get through to the practice on the phone?
Very poorPoorFairGoodVery goodExcellentDon't know/Never tried
8 b) Ability to speak to a doctor on the phone when you have a question or need
medical advice?
Very poorPoorFairGoodVery goodExcellentDon't know/Never tried
9 a) In general, how often do you see your usual doctor?
AlwaysAlmost alwaysA lot of the timeSome of the timeAlmost neverNever
9 b) How do you rate this?
Very poorPoorFairGoodVery goodExcellent
10 a) Thinking about when you consult your doctor, how thoroughly the doctor
asked about your symptoms and how you are feeling?
Very poorPoorFairGoodVery goodExcellentDoes not apply
10 b) How well the doctor listens to what you had to say?
Very poorPoorFairGoodVery goodExcellentDoes not apply
10 c) How well the doctor puts you at ease during your physical examination?
Very poorPoorFairGoodVery goodExcellentDoes not apply
10 d) How much the doctor involves you in decisions about your care?
Very poorPoorFairGoodVery goodExcellentDoes not apply
10 e) How well the doctor explains your problems or any treatment that you need?
Very poorPoorFairGoodVery goodExcellentDoes not apply
10 f) The amount of time your doctor spends with you?
Very poorPoorFairGoodVery goodExcellent
10 g) The doctor's patience with your questions or worries?
Very poorPoorFairGoodVery goodExcellentDoes not apply
10 h) The doctor's caring and concern for you?
Very poorPoorFairGoodVery goodExcellentDoes not apply
11) Have you seen a nurse from your practice in the past 12 months?
Yes - go to question 12No - go to question 13
12 a) Thinking about the nurse(s) you have seen, how do you rate the following:
How well they listen to what you say?
Very poorPoorFairGoodVery good
12 b) The quality of care they provide?
Very poorPoorFairGoodVery goodExcellent
12 c) How well they explain your health problems or any treatment that you need?
Very poorPoorFairGoodVery goodExcellent
13) Are you:
MaleFemale
14) How old are you?
0-1516-2424-3536-5050-6565 and over
15) Do you have any long-standing illness, disability or infirmity? By
long-standing we mean anything that has troubled you over a period of time or
that is likely to affect you over a period of time.
YesNo
16) Which ethnic group do you belong to?
WhiteBlack or Black BritishAsian or Asian BritishMixedChineseOther Ethnic Group
17) Is your accommodation?
Owner occupied/mortgagedRented or other arrangements
18) Which of the following best describes you?
Employed (full or part-time, including self-employed)Unemployed and looking for
workAt school or in full time educationUnable to work due to long term
illnessLooking after your home/familyRetiredOther
19) We are interested in any other comments you may have. Please enter them
below.
TRAVEL QUESTIONNAIRE
Travel Questionnaire
Personal Details
Name:(Required)
Sex:
MaleFemale
Date of birth:(Required)
MM slash DD slash YYYY
Daytime tel:(Required)
Postcode:(Required)
Email:(Required)
Trip Dates
Trip departure:(Required)
DD slash MM slash YYYY
Trip duration:(Required)
Itinerary
Country:(Required)
Duration:(Required)
Availability of medical help:
Country:(Required)
Duration:
Availability of medical help:
Country:
Duration:
Availability of medical help:
Country:
Duration:
Availability of medical help:
Country:
Duration:
Availability of medical help:
Trip Description - please tick all appropriate boxes:
Purpose of trip:
Business
Pleasure
Other
Type of trip:
Package
Self-organised
Backpacking
Camping
Cruise ship
Trekking
Accomodation:
Hotel
Friends/family
Other
Travelling:
Alone
With friends/family
In a group
Location type:
Urban
Rural
Altitude
Activity type:
Safari
Adventure
Other
Personal medical history
List all chronic medical conditions that you have (eg. diabetes, heart or lung
conditions)
If you have had a serious reaction to a vaccine in the past, which vaccine was
it?
List all of your current medications (including oral contraception)
Untitled
Have you recently suffered from any infection (e.g heavy cold, flu or high
temperature)?
Untitled
Does having an injection cause you to feel faint?
Untitled
Do you or any close family members have epilepsy?
Untitled
Do you have any history of mental illness including depression or anxiety?
Untitled
Have you recently undergone radiotherapy, chemotherapy or steroid treatment?
Untitled
Have you taken out travel insurance?
Untitled
If you have a medical condition, have you told your insurance company about it?
Untitled
Are you pregnant, planning pregnancy or breast feeding?
Write below any further information that might be relevant
Have you ever had any of the following vaccinations / tablets and if so, when?
Tetanus
Polio
Diptheria
Typhoid
Hepatitis A
Hepatitis B
Meningitis
Yellow Fever
Influenza
Rabies
Jap B Enceph
Tick Borne
Malaria tablets
Other
YOUR ACCESSIBILITY NEEDS
Your Accessibility Needs
We want to get better at communicating with our patients. We want to make sure
you can read and understand the information we send you. If you find it hard to
read our letters or if you need someone to support you at appointments, please
let us know.
Your Details
Title
Mr.Mrs.Miss.Ms.
Date Of Birth(Required)
DD slash MM slash YYYY
First name:(Required)
Surname:(Required)
Home address:(Required)
Postcode:(Required)
Home tel:(Required)
Please tell us what communication requirements you have (eg. braile, large
print, etc)
SICK NOTE REQUEST FORM
Requesting Fit Note (Med3)
The more information you put in this form, the more opportunity we have to help
you with your Fit note request
Your details:
Title:
Mr.Mrs.Miss.Ms.
Date of birth:(Required)
DD slash MM slash YYYY
First name:(Required)
Surname:(Required)
Email:(Required)
Postcode:(Required)
Telephone:(Required)
The next part of this form, is you opportunity to clarify why you are asking for
a fit note.
Medical reason for sick note request:(Required)
Proposed Fit Note Start Date(Required)
DD slash MM slash YYYY
Proposed Fit Note End Date(Required)
DD slash MM slash YYYY
Why do you feel that your medical condition stops you from working?(Required)
What investigations/treatment have you been doing/taking for the above medical
condition?(Required)
What evidence do you have from your specialist specifying that you cannot
work?(Required)
Please email any supporting documents to docman.e84066@nhs.net
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