New Patient Registration

About You

Surname: *

Forename(s): *

Gender: *

NHS Number:

Place of Birth: *

Current Home Address: *

Postcode: *

Email Address: *

Mobile Number:

Work Telephone Number:

Ethnicity

Please specify:

First Language:

Languages Spoken:

Is a translator needed?

Yes

No

Carers

Are you a carer?

Yes

No

Please register as a carer using our Register a Carer form.

Making Information Accessible

If you would like us to record your communication needs on your medical record, please indicate below:

Please specify:

Previous Details

Previous address in UK:

Please include postcode.

Name and address of previous GP:

If you are from abroad

Registering with the NHS for the first time in the UK

Date you came to live in the UK:

Please use format DD/MM/YYYY

If you are returning from abroad

Previously been registered with the NHS in the UK

Date you left the UK:

Please use format DD/MM/YYYY

Date you returned to the UK:

Please use format DD/MM/YYYY.

Your Health Status

Smoking Status: *

Never Smoked

Ex-Smoker

Current Smoker

Date Stopped:

Please use date format DD/MM/YYYY

Average Amount of Cigarettes a Day: *

Would you like to be referred to the Quit 51 smoking cessation service?

Yes

No

Alcohol

This is one unit of alcohol:

And each one of these, is more than one unit:

Amount of different types of drink representing more than one unit of alcohol

How often do you have a drink that contains alcohol? *

How many alcoholic drinks do you have on a typical day when you are drinking? *

How often do you have 6 or more standard drinks on one occasion? *

Alergies/Intolerances

Please list any drugs, food or other substances to which you are allergic (i.e. you develop a rash/swelling/anaphylactic shock) or drugs to which you are intolerant (i.e. side effects such as diarrhoea or nausea).

Medications and Prescriptions

Please provide a list of any repeat medications you are taking:

Sheerwater Health Centre is an electronic prescribing practice and we are phasing out paper prescriptions where possible. Please nominate the pharmacy where you would like to collect your prescriptions and we will send them there electronically.

Name of Pharmacy:

Pharmacy Address:

Pharmacy Postcode:

Family History

Please indicate if either of your parents, a sibling or a child has been affected by:

What type of cancer?

Age when affected by cancer:

Health Questionnaire

If you have been registered with an NHS GP in England previously, we should receive your medical records electronically – please skip the questionnaire.

Cancer

Have you had Cancer?

Yes

No

Type of Cancer:

Year(s):

Are you receiving treatment?

Yes

No

Heart or Circulatory Problems

Have you had/Do you have:

Lung or Respiratory Problems

Have you had/Do you have:

Asthma

COPD/Emphysema

Tuberculosis

Gastro-Intestinal Problems (Stomach & Gut)

Have you had/Do you have:

Gastro-Urinary Problems

Do you have/Have you had:

Epilepsy

Do you have Epilepsy?

Yes

No

Have you been fit free for over 12 months?

Yes

No

When did you last have a fit, approximately?

How often do you have fits?

Diabetes

Which of the following are used to control your diabetes?

Diet

Tablets

Insulin

Other injections

Bone & Joint Problems

Hip Replacement

Left

Right

Both

Knee Replacement

Left

Right

Both

Other joint replacement:

Rheumatoid Arthritis

Osteoporosis

Gout

Mental Health

Skin Problems

Do you have/Have you had:

Eczema

Ulcers

Psoriasis

Other Conditions

Do you have/Have you had:

Overactive Thyroid

Underactive Thyroid

Migraine (with aura)

For Women Only

Method of Contraception:

Result of Last Cervical Smear:

Normal

Abnormal

Details of follow up:

Any other significant medical problems or operations:

Application for Access to Online Services

I wish to have access to the following online services:

Booking Appointments

Requesting Repeat Prescriptions

Accessing my Medical Record

Please tick the following statements to confirm your agreement: *

I will be responsible for the security of the information that I see or download

If I choose to share my information with anyone else, this is at my own risk

If I suspect that my account has been accessed by someone without my agreement, I will contact the practice as soon as possible

If I see information in my record that is not about me or is inaccurate, I will contact the practice as soon as possible

Signed:

Date:

Consent for Someone Else to Act on Your Behalf

We are unable to discuss any aspect of your care or give your prescriptions to anyone other than you unless we have your express permission. If you would like to give consent for a family member, friend or carer to act on your behalf please complete the following:

I give consent to the following person:

Name:

Relationship to you:

To:

Collect Prescriptions on my behalf

Discuss my health and care with practice staff

Signed:

Date:

Consent for Communication:

At Sheerwater Health Centre, we use texts to keep you informed about your appointments and to send related healthcare messages.

If you have provided a mobile phone number you will be automatically enrolled for text messages about your direct care such as appointment reminders.

Please be aware that if you opt-out, you will not receive appointment reminders.

I do not want to receive text messages about my direct care.

The practice may also contact you by email:

I do not want to receive emails about my direct care

Your consultation may be conducted by video link with a health care professional:

I do not want to have a consultation by video link

Summary Care Record

An electronic Summary Care Record is automatically created for you when you register. It contains brief health information such as your medications and allergies and can be viewed by clinicians who are treating you in other settings in England, such as A&E, Ambulance Services, other GP surgeries and out of hours services.

I do not want to share my information using the Summary Care Record

National Data Opt Out (Sharing of your personal information for purposes other than your own direct care)

NHS Digital collects health information from GP records, hospitals and other healthcare providers for planning and research purposes - sometimes this data includes information that could identify you. You are entitled to opt-out of your data being used in this way. Making this choice won’t affect the care you receive in any way.

You can opt-out online on the NHS Choices website www.nhs.uk from 25th May 2018. NHS Digital will be providing a non-digital alternative for patients who can’t or don’t want to use an online system.

The National Data Opt-out replaces the previous Type 2 opt-outs which patients registered with their GP.

GPDR ( General Data Protection Regulations May 2018)

How we use your information

We collect and hold data about you for the purpose of providing safe and effective healthcare
Your information may be shared with our partner organisations to audit services and help provide you with better care
Information sharing is subject to strict agreements on how it is used
If you are happy with how we use your information you do not need to do anything
If you do not want your information to be used for purpose beyond providing your care please let us know so we can code your record appropriately
You can object to sharing information with other health care providers but if this limits your treatment options we will tell you
Our guiding principle is that we are holding your information in the strictest confidence
We will only share your information outside of our partner organisations with your consent – unless the health and safety of others is at risk, the law requires it, or it is required to carry out a statutory function

Child Registration