New Patient Registration

If you are registering a child under the age of 18, it is preferable if you supply us with a copy of the patients birth certificate for safeguarding reasons.

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Your Identity

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

Are you filling this form out on behalf of someone else: *

Patient's Details

Title: *

Gender: *

Which is your preferred contact phone number?: *

Are you happy for us to contact you by email?:

Are you happy for us to contact you by letter? :

Are you happy for us to contact you by text message? :

We will use text (as appropriate) to contact you unless you tell us otherwise.

Do you have any special needs that will require assistance at the surgery?: *

If you have any particular communication needs you will be asked at the end of this form.

Do you have a nominated pharmacy for electronic prescribing?:

If no preference is given, prescriptions will be held at the surgery for collection. Please allow 3 working days for us to send prescriptions to a pharmacy.

Do you have children?: *

Ethnicity & Religion

Please specify the ethnic group you consider you belong to: *

Your Religion:

Do you speak English?:

Do you read English?:

Emergency Contact

Are they your Next of Kin?:

Do you give us permission to discuss your medical records with them?:

Allergies

Do you have any allergies?: *

Previous Details

Please include postcode

Are you registering for the first time in the UK? : *

Are you returning from abroad?: *

If you are from abroad

Please use this date format: DD/MM/YYYY

Refugee: *

Asylum Seeker: *

Do you require an interpreter when you see the doctor/nurse?: *

Are you returning from abroad? : *

If you are returning from abroad

Previously been registered with the NHS in the UK

Please use this date format: DD/MM/YYYY

Were you ever registered with an Armed Forces GP

Were you ever registered with an Armed Forces GP: *

Please indicate if you have served in the UK Armed Forces and/or been registered with a Ministry of Defence GP in the UK or overseas:

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

Please select one of the following statements::

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

Do you live in another EEA country, or have moved to the UK to study or retire, or live in the UK but work in another EEA member state?:

Do you have a non-UK European Health Insurance Card (EHIC) or a Provisional Replacement Certificate (PRC) ?:

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

Do you have a carer?: *

Are you a carer for someone?: *

Do you give us permission to discuss your medical record with your carer?: *

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Lifestyle

Smoking Status: *

Are you interested in advice on how to quit?: *

Your Personal Alcohol Consumption

alcohol consumption Image 1 unit

How often did you have a drink containing alcohol in the past year?: *

How many drinks containing alcohol did you have on a typical day when you were drinking in the past year?: *

How often did you have six or more drinks on one occasion in the past year?: *

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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Adult Females

Please tell us the date of your last smear test

Was it done at:

Have you had a hysterectomy?:

Do you still have your ovaries?:

Have you every had a blood transfusion?:

Immunisation History

Please select any immunisations / vaccinations you have had

Childhood:

Adult:

e.g. Hepatitis A, B, Rabies etc.

Medical History

Family Medical History

Please provide us with as much information as you can.

Significant illnesses or if deceased, age & cause of death

Past Medical History

Please tick if you have ever suffered from the following:

List previous illnesses and operations including dates. Indicate any from which you still suffer or receive treatment.

Please list any medication you are currently taking, please tell us as much information as possible.

How do you describe your sight?:

How do you describe your hearing?:

Patient Aged 65 and Over

Have you had a flu vaccination this year?:

If No, would you like one this year?:

Over 75 years old?

The Department of Health has advised that all patients of 75years and older have a named and accountable GP to oversee their care. Please ask the name of the GP assigned to oversee your care. Please note this does not prevent you from seeing the GP of your choice.

Please select where you would like us to send your prescription

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Summary Care Record

Summary Care Record (SCR)

The Summary Care Record (SCR) system is designed to help both your GP and any emergency staff you contact when the surgery is closed to treat your health needs more efficiently.

Your information will be shared between your GP practice, our local hospital and Out Of Hours service. This will enable your GP surgery to access results and any visits you have at the hospital quickly and efficiently, but it also means that if you have an emergency and contact the Out Of Hours service or visit A&E they will have access to your current medications as well as allergies and are better able to treat you.

SCR Options: *

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

Systemone

SystmOne

We use a computer system called SystmOne that gives your GP the facility to share your full electronic records across different NHS Care Services that are involved in your care.

It allows you to book appointments online, request repeat medications and view your medical history and test results. You can also update your address and contact information, and it allows you to answer review questionnaires (currently we are trialling this for some asthma patients and hope to extend this to other medical conditions). You can download the SystmOnline app on your smartphone or tablet, or you can access the website via your laptop or desktop

If you agree for us to use these services, we will then send you your log in information to either you mobile number or email address.

Once you have registered for SystmOnline, you can then request access to your detailed coded record where you can view your test results amongst other bits of information. Detailed coded record access needs to be approved by your GP so this will not be accessible straight away.

If you are a carer or have a child under the age of 11 and require proxy access, please contact reception for a sign up form with a piece of photo ID (like a driver’s license or passport).

Allowing your GP to share your record in the SystmOne database helps to deliver better and safer care for you. You can choose to share or not to share your electronic GP record with other NHS Care Services.

If you chose to decline sharing you are able to determine if data is ‘shared out’ and/or ‘shared in’

Would you like to sign up for SystmOnline: *

Sharing Out

Do you consent to the sharing of data recorded by your GP practice with other NHS organisations that may care for you?: *

Sharing In

Do you consent to your GP Practice viewing data that is recorded at other NHS organisations and care services that may care for you: *

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The NHS APP

Also allows you to book appointments online, request repeat medications, view your medical history and test results, as well as links to NHS 111 help pages to check symptoms. You can even change your organ donor registration decisions.

You can currently only sign up to this via a smartphone or tablet through an app (there is no desktop site just yet).

The sign up process is simple; you put in your details, and record a short, four second long video for verification. To download the app search for ‘NHS App’ on the App Store or Google Play and register from home.

FIND OUT MORE

NHS App Advert

AccuRx

If you need help with a non-urgent medical or admin request.

You do not need to register to use this service.

CONSULT ONLINE FROM HOME

eConsult

eConsult allows you to start an online consultation with your doctor, with a response usually by the end of the next working day. It also points you in the right direction for help and treatment, and can actually help save appointments for people that need them more.

You do not need to register to use this service.

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Identification Upload

Patient Identification

Whilst this it not mandatory, we ask you to provide Two forms of Acceptable ID

One item of photo ID is provided, along with One document containing your address)

Acceptable Identification: Birth certificate, Bank/building society card/statement, Marriage certificate, National Insurance Number Card, Medical Card, Payslip, Driving Licence, Letter from Benefits Agency/benefit book/signing on card, Passport Papers from the Home Office, Local authority rent card, P45, Paid utility bills

If you are registering a child under the age of 18, it is preferable if you supply us with a copy of the patients birth certificate for safeguarding reasons.

Only following file extensions are allowed: jpg, jpeg, png, webp, pdf, doc, docx, pptx

Accessible Information Needs

We wish to understand and record any particular communication needs you might have. We will then do our best to meet your needs in all contacts with the Practice.

Is your communication with others affected by a health problem or disability which has lasted, or is expected to last, at least 12 months? : *

Can we share this information with other health and social care providers?: *

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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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New Patient Registration

you have a score of

Please select any immunisations / vaccinations you have had

Family Medical History

Past Medical History

Patient Aged 65 and Over

Summary Care Record (SCR)

SystmOne

The NHS APP

AccuRx

eConsult

Patient Identification

Privacy Consent

STARCROSS SURGERY

EXMINSTER SURGERY

PRACTICE POLICIES

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