Patient Registration Form - 15 years and over

Fields marked "REQUIRED" are compulsory. You should only send this form if you are sure that you are eligible to join this practice. Sending this form will NOT automatically register you with the surgery. Your details will be held at the surgery for a limited period of time. You are required to present in person to sign your registration form and provide proof of your address. Sending this form does NOT guarantee or even imply that you will be accepted onto the practice register.

Last Updated: 03/08/2020

Patients Details

Title

Surname *

First name(s) *

Previous Surname *

Birth Town *

Birth Country *

Date of Birth *

NHS number *

Sex

Male

Female

Address *

Postcode *

Telephone *

I am a student at

Please help us trace your previous medical records by providing the following

Help us trace your previous medical records

Your previous address in UK

Name of previous GP while at previous address

Address of that Doctor

If you are from abroad

Please provide details only if you're from abroad

Your first UK address where registered with a GP

If previously resident in UK, date of leaving

Date you first came to live in UK

If you are returning from the armed forces

Please provide details only if you are returning from the armed forces

HAVE YOU SERVED IN THE ARMED FORCES AND/OR BEEN REGISTERED WITH A MINISTRY OF DEFENCE GP IN THE UK OR OVERSEAS

REGULAR

RESERVIST

VETERAN

FAMILY MEMBER

Address before enlisting

Service/Personnel No.

Enlistment date

DISCHARGE DATE (IF APPLICABLE)

Complete Registration

Please complete details below

If you need your doctor to dispense medicines and appliances

I live more than 1 mile in a straight line from the nearest chemist

I would have serious difficulty in getting them from a chemist

Signature

Signature of patient

Signature on behalf of patient

Date

NHS Organ Donor Registration

I want to register my details on the NHS Organ Donor Register as someone whose organs/tissue may be used for transplantation after my death. For more information, please ask for the leaflet on joining the NHS Organ Donor Register

Please tick the boxes that apply

Any of my organs and tissue or

Kidneys

Heart

Liver

Corneas

Lungs

Pancreas

Any part of my body

Signature confirming consent to organ donation

Date

NHS Blood Donor Registration

For more information, please ask for the leaflet on joining the NHS Blood Donor Register

I would like to join the NHS Blood Donor Register as someone who may be contacted and would be prepared to donate blood.

Tick here if you have given blood in the last 3 years

Signature confirming consent to inclusion on the NHS Blood Donor Register

Date

Preferred address for donation: (if different from above, e.g. place of work)

Postcode

SUPPLEMENTARY QUESTIONS | PATIENT DECLARATION for all patients who are not ordinarily resident in the UK

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 from your GP practice. 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.

Please tick one of the following boxes:

I understand that I may need to pay for NHS treatment outside of the GP practice

I understand I have a valid exemption from paying for NHS treatment outside of the GP practice. This includes for example, an EHIC, or payment of the Immigration Health Charge ('the Surcharge'), when accompanied by a valid visa. I can provide documents to support this when requested

I do not know my chargeable status

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.

Are you a parent or guardian, filling out this form on behalf of a child under 16?

Name parent or guardian

Relationship to patient:

Signed

Date

NON-UK EUROPEAN HEALTH INSURANCE CARD (EHIC), PROVISIONAL REPLACEMENT CERTIFICATE (PRC) DETAILS and S1 FORMS

Complete this section if you live in another EEA country, or have moved to the UK to study or retire, or if you live in the UK but work in another EEA member state. Do not complete this section if you have an EHIC issued by the UK. 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 the GP practice, including at hospital).

Do you have a non-UK EHIC or PRC?

Yes No

If yes, please enter details from your EHIC or PRC below:

Country Code:

Name:

Given Names:

Date of Birth

Personal Identification Number:

Identification number of the institution:

Identification number of the card:

Expiry Date:

PRC VALIDITY PERIOD From:

PRC VALIDITY PERIOD To:

Please tick if you have an S1 (e.g. you are retiring to the UK or you have been posted here by your employer for work or you live in the UK but work in another EEA member state). Please give your S1 form to the practice staff.

I have an S1 form

Next of Kin

Please add next of kin

NAME

RELATIONSHIP

NEXT OF KIN ADDRESS

NEXT OF KIN CONTACT NUMBER

CARER

Please add Carer details

DO YOU HAVE A CARER

YES

ARE YOU A CARER

YES

THEIR RELATIONSHIP TO YOU

CARER'S CONTACT TELEPHONE NUMBER

CARER'S ADDRESS

PLEASE ADVISE OF ANY DISABILITIES YOU HAVE

MEDICAL RECORD CONSENT

Please give details below of anyone you wish to have full access to your medical records including test results and other confidential information.

NAME

DATE OF BIRTH

TELEPHONE NUMBER

RELATIONSHIP TO PATIENT

SIGNATURE OF PATIENT CONFIRMING MEDICAL RECORD CONSENT

DATE OF SIGNATURE

SMOKING

(We strongly recommend that you do not smoke and we offer appointments and leaflets to assist you to stop smoking)

Are you a smoker? *

Yes No

IF NO, ARE YOU AN EX SMOKER?

Yes No

IF AN EX SMOKER, WHAT YEAR DID YOU STOP?

IF A SMOKER, HOW MANY CIGARETTES DO YOU SMOKE A DAY?

IF A SMOKER, HOW MANY CIGARS DO YOU SMOKE A DAY?

ALCOHOL

It is a government priority to address the issue of illness associated with alcohol consumption. From 2008 GP practises are required to record for all new patients aged over 16 the amount of alcohol consumed. As you are registering at the practise please answer the questions below. Dependent on your total score the practice may invite you for an appointment with the nursing team for a review.

EXERCISE

Please add details on Excercise

HOW OFTEN DO YOU EXERCISE? *

Heavy exercise (eg. 20 minutes, 3 times a week and more)

Moderate exercise (eg. brisk walks, 3 times a week)

Light exercise (walks to shops, gardening etc.)

Exercise physically impossible

CURRENT HEIGHT (shoes removed)

CURRENT WEIGHT (In light clothing)

ETHNIC ORIGIN

Please provide your Ethnic Origin

PRESCRIPTIONS

We are now using the Electronic Prescription Service (EPS) within our surgery. This enables GPs and practice nurses to send prescriptions electronically to a pharmacy of the patient's choice. This makes the prescribing and dispensing process more efficient and convenient for patients and staff.

If you are allergic to any medications, please state below

Please state the name of the pharmacy you with for your prescriptions to be sent to. (Please note from the day of your prescription request, your items will be ready directly at your nominated chemist after 48 hours).

PAST MEDICAL HISTORY

Please write here details of anything you would like your doctor to know about your past medical history (in particular include if you have had angina, stroke, heart attack, high blood pressure, asthma or any operations). Please (if applicable) also indicate the year of the event and the medication you are taking for these conditions.

WOMEN ONLY

Please provide details only if you're a female.

Have you had a cervical smear in the last 5 years?

Yes

Not sure

If yes, do you know the date?

Patients Online Service - Book GP Appointments and Order Prescriptions

In order to help improve access to appointments and repeat prescription ordering, you can now book appointments online with any of our regular GP Team. You will be able to cancel and check appointments already booked. You can also request repeat prescriptions. This service is available at any time including outside the normal reception hours. In signing up for these services you are aware of the following conditions: 1) I accept responsibility for the password and any access to the system using the password. 2) I am aware that if I divulge the password to other parties, they will be able to access information about me. 3) I agree to inform the Practice immediately if I believe my password has been lost/stolen. 4) The Practice can cancel my access (without notification) if there is abuse of the system such as: booking appointments and not attending, repeatedly booking and then cancelling appointments, repeatedly requesting prescriptions that I do not need. TO ACCESS THIS SERVICE PLEASE EMAIL EVIDENCE OF PHOTOGRAPHIC ID TO llw.c83025@nhs.net

Name

ADDRESS

Email address

DATE OF BIRTH

DATE OF APPLICATION TO ONLINE SERVICES

PLEASE ISSUE ME A PASSWORD TO THE ONLINE SERVICES. SIGN HERE.

Text Messaging Consent

I would like to receive text messages to these telephone numbers from Richmond Medical Centre. I understand that the content may relate to any aspect of the medical record for the patient listed here only and may include confirmation of an appointment, details of test results, or a reminder alert. Should I wish to withdraw consent I accept that I must give at least 5 working days in writing quoting the mobile number below. I will advise the practice if I change my mobile number and understand that a new consent form is required. I am aware that the NHS mail messaging service utilises the public telephone network and as such full security is not guaranteed. Richmond Medical Centre NHS net email address will appear at the bottom of each text.

Mobile number

PATIENT NAME

MOBILE TELEPHONE NUMBER

DATE OF BIRTH

I confirm that I understand the above statement and that I am the patient above. I understand that it is my responsibility to advise the Richmond Medical Centre to stop sending texts to the telephone number listed. Full name:

SIGNED

Patient Contact Waiver and Appointment System Acceptance

Routine appointments with a doctor may be booked up to two weeks in advance only. If you need an urgent appointment you may be offered a same day appointment with the duty doctor. At particularly busy times your appointment may not be on time. In accordance with the Data Protection Act there is a requirement that Practice staff, when required to contact a patient on medical matters relating to the patient, can only speak to the person concerned. If anyone other than the patient answers the phone the member of staff cannot reveal who is calling. This undoubtedly causes frustration not just from a staff perspective but also delays the passing of any messages to the patient in question. This is particularly so in the case of communicating results.

Are you happy if a message is left with a member of your household saying that you have received a call from Richmond Medical Centre? *

Yes No

Are you happy for a member of your household to take a message for you? *

Yes No

Are you happy for a message to be left on any answerphone you may have at your home address asking you to contact Richmond Medical Centre? *

Yes No

Are you happy for any message to be left via voicemail on any mobile number that is registered to you

are you happy for a message asking you to contact the practice to be sent bia any email account you may have? This would include any family type email addresses that are registered at your home address and is used for email purposed by more than one family member? *

Yes No

In signing this statement I confirm that I understand the appointment system and that I have agreed to those options that I have circled above and recognise that this authorisation will remain in force for the duration of the time that I remain a patient at Richmond Medical Centre or until such time as I give notice that I wish to revoke any of the declarations that I have made above. Signed: *

Sharing your information locally

Information about Sharing your information locally

I WOULD / WOULD NOT like the information recorded at Richmond Medical Centre to be available to be seen by other care teams who are involved in my care where I have granted those care teams access to see my shared data. *

I would

I would not

I Would / I would not like the information recorded at other care teams who are involved in my care to be seen by members of the team at Richmond Medical Centre, where I have granted those care teams the right to add to my shared data. *

I would

I would not

Sharing your information nationally

Your Summary Care Record will contain information about any medicines you are taking, allergies you suffer from and any bad reactions to medicines you have had to ensure those caring for you have enough information to treat you safely. Your Summary Care Record will be available to authorised healthcare staff providing your care anywhere in England, but they will ask your permission before they look at it. This means that if you have an accident or become ill, healthcare staff treating you will have immediate access to important information about your health.

We are supporting Summary Care Record and as a patient you have a choice:

Yes I would like a Summary Care Record

No I do not want a Summary Care Record

Patient Opt Out Form: HSCIC data sharing

The Health and Social Care Information Centre collects data about you in a way that you cannot be identified by it.

If you wish to prevent your data being used please opt out

I would like to opt out

Patient Registration Form - 15 years and over

Further Information