New Patient Registration

 

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Please complete our online form

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Personal Information
 
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Gender and Sexuality
 
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Country of Birth
Ethnic Origin
Religion
 
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Residential status
Occupation
Overseas Visitor
 
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Military veteran
 
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Communication Consent
Spoken Language
Communication Needs
 
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Carer Status

Carer’s details (name, address and contact number)

*Only add carer’s details if they give their consent to have these details stored on your medical record

 
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Medical History
Family History
Allergies
Medications
Prescription consent
 
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Disabilities
 
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Your Personal Alcohol Consumption

alcohol consumption Image 1 unit

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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Lifestyle
 
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Activity (GPPAQ)

During the last week, how many hours did you spend on each of the following activities?

 
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Body Mass Index
Blood Pressure
 
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Women Only
 
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Students Only

Students are at risk of certain infections including mumps, meningitis and sexually transmitted infections, as well as mental health issues including stress, anxiety and depression. Please see the NHS website

 
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Digital literacy
Patient Participation Group
Summary Care Record
Local shared electronic health record
3rd party, LPA & DNACPR

Power of attorney status: Personal Details of Power of attorney: 
The Surgery may ask you to provide proof of power of attorney.

 
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Your Data Matters

The NHS wants to make sure you and your family has the best care now and in the future. Your health and adult social care information supports your individual care. It also helps us to research, plan and improve health and care services in England.

There are very strict rules on how this data can and cannot be used, and you have clear data rights. We are committed to keeping patient information safe and will always be clear on how it is used.

You can choose whether or not your confidential patient information is used for research and planning.

If you do not wish your information to be used in this way, please opt-out by visiting the NHS website or calling 0300 303 5678.

The practice is unable to record this for you.

 
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Signatures
 
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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?

Organisation Name 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 the NHS website

For further information about how the NHS uses your data for research & planning and to opt-out, please see the NHS website

 
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Online Access To Your Health Record

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 the NHS website

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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