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

Patient Registration Form - 15 years and over















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

Help us trace your previous medical records




If you are from abroad

Please provide details only if you're from abroad




If you are returning from the armed forces

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






Complete Registration

Please complete details below




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




NHS Blood Donor Registration

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






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.







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).














Next of Kin

Please add next of kin





CARER

Please add Carer details







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.







SMOKING

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






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




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.



PAST MEDICAL HISTORY


WOMEN ONLY

Please provide details only if you're a female.



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







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.







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.







Sharing your information locally

Information about Sharing your information locally



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.


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.