Patient Registration Form – Adult

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1. Background Details

Contact Details

Checkboxes

I do not know my NHS number

NHS Number

If you have had a previous GP then you will find this on letters/prescriptions or at www.nhs.uk/find-NHS-number

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Name

Which of the following best describes how you think of yourself?

Is your gender the same as the sex you were assigned at birth?

Previous Surname (if applicable)

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Address

Date of Birth

Home Telephone

Work Telephone

Previous Address

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Mobile Telephone

I consent to be contacted* by SMS on this number:

I consent to be contacted* by email at this address:

Next of Kin

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Name

Tel

Relationship

Family Registered With Us

Has the patient been registered in the NHS before?

* It is your responsibility to keep us updated with any changes to your telephone number, email & postal address. We may contact you with appointment details, test results, health campaigns or Patient Participation Group details If you do not consent to being contacted by SMS or Email, please tick here:

Other Details

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Previous GP Name

Country of Birth

Previous GP Address

Overseas Visitor

Yes
European Health Insurance Card Held

Armed Forces

Military Veteran
Family member

Communication Needs

What is your main spoken language?

Do you need an interpreter?

Do you have any communication needs?

Do you have a Learning Disability?

Do you have a carer?

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2. Medical History

If you are currently under the care of a Hospital or Consultant outside our area, please tell us here:

Family History

Allergies

Please record any allergies or sensitivities below

Vaccinations

Have you had all their routine vaccinations?

3. Your Lifestyle

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How often do you have a drink containing alcohol?

How many units of alcohol do you drink on a typical day when you are drinking?

How often during the last year have you had a feeling of guilt or remorse after drinking?

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How often during the last year have you found that you were not able to stop drinking once you had started?

How often during the last year have you failed to do what was normally expected from you because of your drinking?

How often during the last year have you needed an alcoholic drink in the morning to get yourself going after a heavy drinking session?

How often have you had 6 or more units if female, or 8 or more if male, on a single occasion in the last year?

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How often during the last year have you been unable to remember what happened the night before because you had been drinking?

Have you or somebody else been injured as a result of your drinking?

Has a relative or friend, doctor or other health worker been concerned about your drinking or suggested that you cut down?

Smoking

Do you smoke?

Never smoked
Ex-smoker
Yes

Do you use an e-Cigarette?

No
Ex-User
Yes

Would you like help to quit smoking?

Height & Weight

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Height

Weight

Waist Circumference

Blood Pressure (if known)

Date inserted

Students Only

Are you a Student

I am less than 24 years old and have had two doses of the MMR Vaccination

Yes
No
Unsure

I am less than 25 years old and have had a Meningitis C Vaccination

Yes
No
Unsure

4. Further Detail

How well do you use a mobile phone or internet to communicate with your GP Practice

I am able to use Information Technology to communicate with my Practice

I have difficulty using Information Technology to communicate with my Practice

I am unable to use Information Technology

Named Accountable GP

The GP who has overall responsibility for your care is?

You are however entitled to make an appointment to see any GP of your choice, subject to availability.

Electronic Prescribing If you would like your prescriptions to be sent electronically, please provide details of the pharmacy you would like to use:

Pharmacy

Patient Participation Group

Would you like to be involved in our Patient Participation Group

We are committed to improving the services we provide. The Patient Participation Group is a mechanism for us to gain valuable feedback from our patients about their experiences, views and ideas for improving our services.

Blood and Organ Donation

Blood Donation If you are interested in blood donation and would like to register as a blood donor, please visit https://www.blood.co.uk/ Organ Donation If you are interested in organ donation and would like to register your decision, please visit: https://www.organdonation.nhs.uk/

Signatures

I confirm that the information I have provided is true to the best of my knowledge.

Signed on behalf of patient

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Uploads Please ensure the following are done and provided so that your registration can be completed successfully

Photo Proof of ID

Click or drag a file to this area to upload.

e.g. Passport, Photo Driving License or Photo ID card

Proof of Address

Click or drag files to this area to upload. You can upload up to 3 files.

e.g. Bank statement, Utility Bill or Council Tax from within the last 3 months

Your Health Record

Do you consent to your GP Practice sharing your health record with other organisations who care for you?

Yes (recommended option)
No, never

Do you consent to your GP Practice viewing your health record from other organisations that care for you?

Yes (recommended option)
No

Your Summary Care Record (SCR)

Do you consent to having an Enhanced Summary Care Record with Additional Information?

Yes (recommended option)
No

Sharing Your Health Record

What is your health record?

Your health record contains all the clinical information about the care you receive. When you need medical assistance it is essential that clinicians can securely access your health record. This allows them to have the necessary information about your medical background to help them identify the best way to help you. This information may include your medical history, medications and allergies.

Why is sharing important?

Health records about you can be held in various places, including your GP practice and any hospital where you have had treatment. Sharing your health record will ensure you receive the best possible care and treatment wherever you are and whenever you need it. Choosing not to share your health record could have an impact on the future care and treatment you receive. Below are some examples of how sharing your health record can benefit you:

Sharing your contact details This will ensure you receive any medical appointments without delay
Sharing your medical history This will ensure emergency services accurately assess you if needed
Sharing your medication list This will ensure that you receive the most appropriate medication
Sharing your allergies This will prevent you being given something to which you are allergic
Sharing your test results This will prevent further unnecessary tests being required

Is my health record secure?

Yes. There are safeguards in place to make sure only organisations you have authorised to view your records can do so. You can also request information regarding who has accessed your information from both within and outside of your surgery.

Can I decide who I share my health record with?

Yes. You decide who has access to your health record. For your health record to be shared between organisations that provide care to you, your consent must be gained.

Can I change my mind?

Yes. You can change your mind at any time about sharing your health record, please just let us know.

Can someone else consent on my behalf?

If you do not have capacity to consent and have a Lasting Power of Attorney, they may consent on your behalf. If you do not have a Lasting Power of Attorney, then a decision in best interests can be made by those caring for you.

What about parental responsibility?

If you have parental responsibility and your child is not able to make an informed decision for themselves, then you can make a decision about information sharing on behalf of your child. If your child is competent then this must be their decision.

What is your Summary Care Record?

Your Summary Care Record contains basic information including your contact details, NHS number, medications and allergies. This can be viewed by GP practices, Hospitals and the Emergency Services. If you do not want a Summary Care Record, please ask your GP practice for the appropriate opt out form. With your consent, additional information can be added to create an Enhanced Summary Care Record. This could include your care plans which will help ensure that you receive the appropriate care in the future.

How is my personal information protected?

will always protect your personal information. For further information about this, please see our Privacy Notice on our website or please speak to a member of our team

For further information about your health records, please see: https://www.nhs.uk/using-the-nhs/about-the-nhs/your-health-records/

For further information about how the NHS uses your data for research & planning and to opt-out, please see: www.nhs.uk/your-nhs-data-matters

6. Online Access To Your Health Record

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Name

NHS Number

Date

Address

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Telephone

Email Address

I wish to have online access to: Please tick all that apply

I wish to access my medical record & understand & agree with each statement: Please tick all that apply

I have read and understood the ‘Important Information’ section below
I will be responsible for the security of the information that I see or download
If I choose to share my information with anyone else, this is at my own risk
I will contact the practice as soon as possible if I suspect that my account has been accessed by someone without my agreement
If I see information in my record that it not about me, or is inaccurate I will log out immediately and contact the practice as soon as possible

Please upload photographic proof of your identification in order for the sign up process to be completed

Access to GP Online Services

Important Information – Please read before completing form below

If you wish to, you can now use the internet (via computer or mobile app) to book appointments with a GP, request repeat prescriptions for any medications you take regularly and look at your medical record online. You can also still use the telephone or call in to the surgery for any of these services as well. It’s your choice.

It will be your responsibility to keep your login details and password safe and secure. If you know or suspect that your record has been accessed by someone that you have not agreed should see it, then you should change your password immediately. If you are unable to do this for some reason, we recommend that you contact the practice so that they can remove online access until you are able to reset your password.

If you print out any information from your record, it is also your responsibility to keep this secure. If you are at all worried about keeping printed copies safe, we recommend that you do not make copies at all.

During the working day it is sometimes necessary for practice staff to input into your record, for example, to attach a document that has been received, or update your information. Therefore you will notice admin/reception staff names alongside some of your medical information – this is quite normal.

The definition of a full medical record is all the information that is held in a patient’s record; this includes letters, documents, and any free text which has been added by practice staff, usually the GP. The coded record is all the information that is in the record in coded form, such as diagnoses, signs and symptoms (such as coughing, headache etc.) but excludes letters, documents and free text.

Before you apply for online access to your record, there are some other things to consider. Although the chances of any of these things happening are very small, you will be asked that you have read and understood the following before you are given login details.

Forgotten history
There may be something you have forgotten about in your record that you might find upsetting.

Abnormal results or bad news
If your GP has given you access to test results or letters, you may see something that you find upsetting to you. This may occur before you have spoken to your doctor or while the surgery is closed and you cannot contact them.

Choosing to share your information with someone
It’s up to you whether or not you share your information with others – perhaps family members or carers. It’s your choice, but also your responsibility to keep the information safe and secure.

Coercion
If you think you may be pressured into revealing details from your patient record to someone else against your will, it is best that you do not register for access at this time.

Misunderstood information
Your medical record is designed to be used by clinical professionals to ensure that you receive the best possible care. Some of the information within your medical record may be highly technical, written by specialists and not easily understood. If you require further clarification, please contact the surgery for a clearer explanation.

Information about someone else
If you spot something in the record that is not about you or notice any other errors, please log out of the system immediately and contact the practice as soon as possible.

For further information, please see: www.nhs.uk/NHSEngland/AboutNHSservices/doctors/Pages/gp-online-services.aspx