Patient registration report

I’m trying to put together a report to print and give to patients whenever a patient enters my clinic. I see something similar in the private hospital in which I work and I think something similar in my clinic would work well too. In the private hospital, patient details are printed and the patient is asked to check the details and sign at the bottom to confirm the details are correct (probably for DPA purposes). I would probably call this a “Registration Form” or something similar.

I was looking for something similar in ClinicOffice but suspect this is something I’m going to have to make myself. I would need the following fields:

title, name, address, date of birth, tel (home), tel (mobile), email, GP name, GP address, and perhaps some other basic information seen on the full patient record form when opened on the screen. I would also want to put a few questions into the “registration form” (eg tick if you are interested in some of the other services that we offer, how did you find out about us, can we add you to our email newsletter to tell you about our latest offers, etc)

Is there a template that I can modify to make such a report? if not, is it something I can do easily enough, bearing in mind I cannot find an existing report to copy and modify as no current report seems to include all this information.