New Patient Registration

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Patient's Details

Information we need to register you with the practice
Please note all fields marked with a * are mandatory for your registration

Please include postcode
 
 
Additional Questions
e.g. hearing difficulties
Emergency Contact
Online Access

Online Access

If you wish to have full online access to your medical information at this surgery please upload your photo ID. We will confirm your log in details .......

Please speak to reception for more information it needed.

Registration Status
If you are from abroad
Please use this date format: DD/MM/YYYY
If you are returning from abroad

Previously been registered with the NHS in the UK

Please use this date format: DD/MM/YYYY
Please use this date format: DD/MM/YYYY
 
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Were you ever registered with an Armed Forces GP

Footnote: These questions are optional and your answers will not affect your entitlement to register or receive services from the NHS but may improve access to some NHS priority and service charities services

Supplementary Questions

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 at reception. Alternatively for more information go to www.nhs.uk/nhs-services/visiting-or-moving-to-england

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.

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.

A parent/guardian should complete the form on behalf of a child under 16.

European Economic Area (EEA) Country

For a list of EEA countries visit: www.gov.uk/eu-eea

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 of the GP practice, including at a hospital.

Please enter the details from your EHIC or PRC below.

S1 Form

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.

Carers
 
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Lifestyle
e.g. regular exercises = at least 5 times a week for 30 mins
Allergies
Immunisation History

Please list the dates of the following injections.

Have you every suffered from
Mark all that apply
Asthma Control Score

The Asthma Control Test will provide you with a snapshot of how well your asthma has been controlled over the last four weeks, giving you a simple score out of 25. Asthma symptoms can vary from month to month, so it is worth keeping the test handy to see if your score changes. You can also share your results with your doctor or asthma nurse to help explain just how your asthma affects you.

Diabetes
Epilepsy

An appointment will be made for you to meet with your GP once your registration is complete 

Your Score

Off Target

You scored 

Your asthma may not have been controlled during the past 4 weeks.
Your Doctor or Nurse may recommend an asthma action plan to help improve your asthma control once you have submitted this form.

On Target

You scored 

Your asthma appears to have been reasonably well controlled during the past 4 weeks.
However, if you are experiencing symptoms your Doctor or Nurse may be able to help you, please let a Doctor or Nurse know.

Well Done

You scored 

Your asthma appears to have been under control over the last 4 weeks.
However, if you are experiencing symptoms your Doctor or Nurse may be able to help you, please add these into the comments box at the end of this form.

Additional Questions

Additional Questions

Please complete the additional questions below

How to get an asthma action plan

If you’re not using an asthma action plan yet, it’s easy to get started:

  1. Download an asthma action plan here. If you can, print out a copy to take to your GP or asthma nurse.
  2. Book an asthma appointment with your GP or asthma nurse.
  3. At the appointment, talk through the plan with your GP or asthma nurse and fill it in together. You can do this by telephone or video call too if your appointment isn’t in the surgery. Ask them to save a copy onto your notes and send it to you on email, SMS or WhatsApp.
 
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Medical History
 

Family history

Please give details of any diseases in the family that may be hereditary, such as diabetes, raised blood pressure, heart disease, stroke, PE, DVT or mental disorder and who is affected.

Adult Females
Please use this date format: DD/MM/YYYY.
 
 
Your Personal Alcohol Consumption

alcohol consumption Image 1 unit

Full Audit-C
Audit Score Result

you have a score of 

If you are drinking less than 14 units of alcohol per week, then your drinking is within the UK Chief Medical Officers' low risk drinking guidelines.

But if you are drinking regularly at or above the low risk guidelines of 14 units a week, or, you are drinking six or more units - if you are female - or eight or more units - if you are male - in one single session (binge drinking), please consider the increased serious risks to your health being caused by your current drinking pattern.

 
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Summary Care Record

Summary Care Record (SCR)

Custom questions to follow

If you do not return this form, a Summary Care Record will be created for you based on implied consent

 
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Your Health Record and Sharing of information

Your health record includes your medical history, details about your medication and allergies you may have. You can now choose whether to share these full medical details.

We use a secure electronic health records system called SystmOne. With your permission, this system can allow clinicians to share your full record held here with other healthcare services who are providing care for you. These other services will ask your permission to view your record.

Many organisiations may use SystmOne, including some GP practices, out of hours services, children's services, community services and some hospitals. Sharing your health record will help us deliver the best level of care for you.

You have two choices which allow you to control how your record is shared. You can change these choices at any time by letting the relevant practice or service know.

If you have previously opted out of sharing your information via the Summary Care Record, you will still need to complete this form with your choices about sharing your health record with SystmOne.

Sharing OUT - This controls whether your information recorded at this practice or service can be shared with other healthcare services.

Sharing IN - This determines whether or not this practice or service can view information in your record that has been entered by other services who are providing care for you, or may provide care for you in the future.

Imaging you're receiving care from three services: your GP , a district nurse and a smoking clinic. You want your GP and District Nurse to share infomation with each other and you want both of them to know youe progress at the smoking clinic. However, you don't want the smoking clinic to see any of your other medical information.

Your sharing choices at each practice or service would be:

  • The GP can share information IN and OUT
  • The districy nurse can share IN and OUT
  • The smoking clinic can only share information OUT but not IN

You can change your choices at any time. Let each practice or service know.

You can request individual entries in your record to be marked as 'Private'. These are not shared with the rest of your record even if you choose to share out.

The choices you would like to make about sharing your health record:

 
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NHS Organ Donor registration

For more information on organ donation please visit: www.organdonation.nhs.uk

NHS Blood Donor registration

If you would like to join the NHS Blood Donor Register as someone who may be contacted and would be prepared to donate blood, please visit their website on: www.blood.co.uk or call direct on 03001232323

What happens to my information?

Personal and medical information about patients registered at this practice are primarily kept electronically, although some is kept in paper form. Some information will be sent to hospital consultants and other health professionals to whom you are referred by your GP in order to provide continued healthcare and obtain treatment for you.

We sometimes use accredited suppliers for our communication with you, for example when we send recall letters for review clinics or medication reviews. All suppliers we use are checked carefully to ensure they comply with strict confidentiality protocols.

To ensure the security of all patient information, all staff that has access to your records is covered by confidentiality clauses in their contracts and the Data Protection Act and the Freedom of Information Act. Our guiding principle is that we hold your records in strict confidence.

I certify that the information I have provided is correct and consent to my personal and medical information being used as stated above.

Privacy Consent

This form collects personal and medical information about you. We use this information to allow the practice team to contact you. Please read our Privacy Policy to discover how we protect and manage your submitted data.

 
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