New Patient Registration New Patient Registration [Word Document] If you are new to the area and wish to register with the Practice please complete the form below – each person registering will need to complete a form. Step 1 of 5 20% Personal DetailsTitle Mr Mrs Miss Ms Mx Dr Other NHS Number Find your NHS NumberFirst Names Surname Previous Surname Optional Date of Birth Day Month Year Gender Female Male EthnicityPlease SelectWhite – BritishWhite – IrishWhite – TurkishWhite – GreekWhite – KurdishWhite – OtherAsian – IndianBritish IndianAsian – PakistaniBritish PakistaniAsian BangladeshiAsian – OtherBlack – CaribbeanBlack – AfricanBlack – OtherMixed – BritishMixed CaribbeanMixed – AfricanMixed – White & AsianMixed – OtherEthnic – ChineseEthnic – FilipinoEthnic – VietnameseEthic – OtherI do not wish to discloseFirst Spoken Language Town and Country of Birth Address Street Address Address Line 2 City Postcode Main Contact NumberHome Contact Number OptionalEmail Enter Email Optional Confirm Email Optional Please help us trace your previous medical records by providing the following information:Your previous address in the UK Street Address Optional Address Line 2 Optional City Optional Postcode Optional Name of doctor while at that address Optional Address of previous doctor Street Address Optional Address Line 2 Optional City Optional ZIP / Postal Code Optional If you are from abroadYour first UK address where registered with a GP Street Address Optional Address Line 2 Optional City Optional Postcode Optional If previously resident in UK, date of leaving Day Optional Month Optional Year Optional Date you first came to live in the UK Day Optional Month Optional Year Optional Supplementary QuestionsAre you ordinarily a resident in the UK? Yes No European Economic Area (EEA) CountryFor a list of EEA countries visit: www.gov.uk/eu-eeaDo 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? Yes Optional No Optional DemographicsMarital Status Single, never married Married Civil Partnership Divorced Widowed Separated Which of the following options best describes you? Heterosexual or Straight Gay or Lesbian Bisexual Prefer not to say In another way Sex and gender identity – Which one of the following best describes how you think of yourself? Male (including trans men) Female (including trans women) Non-binary Prefer not to say In another way Is your gender identity the same as the gender you were given at birth? Yes No Prefer not to say Please specify the ethnic group you consider you belong to English Welsh Scottish Northern Irish British Irish Gypsy or Irish Traveller Any other White background White and Black Caribbean White and Black African White and Asian Any other Mixed / Multiple ethnic background Indian Pakistani Bangladeshi Chinese Any other Asian background African Caribbean Any other Black / African / Caribbean background Arab Any other ethnic group Prefer not to say What is your main religion? No religion Optional Christian (including Church of England, Catholic, Protestant, and all other Christian denominations) Optional Buddhist Optional Hindu Optional Jewish Optional Muslim Optional Sikh Optional Other religion Optional Communication NeedsDo you speak English? Yes No Do you read English? Yes No Are you a British Sign Language user? Yes No What is your main spoken language? DisabilityDo you have an impairment, health condition or learning difference that has a substantial or long term (over a year) impact on your ability to carry out day to day activities? (Tick all that apply) No known impairment, health condition or learning difference Optional A long standing illness/health condition such as cancer, HIV, diabetes, chronic heart disease, asthma, or epilepsy Optional A mental health impairment, such as depression, schizophrenia or anxiety disorder Optional A physical impairment or mobility issues, such as difficulty using your arms or using a wheelchair or crutches Optional A learning difficulty Optional Neuro-diverse e.g. dyslexic, dyspraxic or AD(H)D Optional Deaf or hearing impaired Optional Blind or have a visual impairment uncorrected by glasses Optional An impairment, health condition or learning difference that is not listed above Optional Prefer not to say Optional Do you have any specific information or communication needs? If so, please specify how we can meet these for you (e.g. large print, Braille, easy read communications) OptionalArmed ForcesHave you served in the UK Armed Forces and/or been registered with a Ministry of Defence GP in the UK or overseas? Yes No Do you have access to secure housing? Yes No What is your current immigration status? Asylum Seeker Optional Failed Asylum Seeker Optional CarersDo you have caring responsibilities? None Primary carer of a child/children (under 18) Primary carer of disabled child/children Primary carer of disabled adult (18 and over) Primary carer of older person Secondary carer (another person carries out the main caring role) Prefer not to say Do you have a carer? Yes No Emergency ContactFull Name Relationship to you Contact NumberAre they your next of kin? Yes No Do you give us permission to discuss your medical records with them? Yes No About YouHeight Weight Smoking Status Current Smoker Ex Smoker Never Smoked What do you smoke? e.g. Cigarettes, Vape, CigarsHow many do you smoke per day? Are you interested in advice on how to quit? Yes No Please state how much exercise and what type of exercise you do per week OptionalAlcohol ConsumptionThis is one unit of alcohol: Half pint of regular Beer/Lager/Cider 1 small glass of wine 1 single measure of spirits 1 single measure of aperitifs 1 small glass of sherry Each of these is more than one unit: Pint of regular Beer/Lager/Cider (2 Units) Pint of Premium Beer/Lager/Cider (3 Units) Alcopop or can/bottle of regular Lager (1.5 Units) Can of Premium Lager/Strong Beer (2 Units) Can of super strength lager (4 Units) Glass of wine (2 Units) Bottle of wine (9 Units) How often do you have a drink containing alcohol? Never Monthly or less 2-4 times per month 2-3 times per week 4+ times per week How many units of alcohol do you drink on a typical day when you are drinking? 1-2 3-4 5-6 7-9 10+ How often have you had 6 or more units if female, or 8 or more if male, on a single occasion in the last year? Never Less than monthly Monthly Weekly Daily or almost daily Do you have any significant family history we should be aware of? OptionalMedical HistoryMajor Illnesses OptionalPlease include datesPast Operations OptionalPlease include datesFamily History Illnesses OptionalPlease include datesCurrent Medication OptionalWe routinely offer HIV screening would you be interested in being screened? Yes No Sight Good Poor Registered Blind Hearing Good Poor Partially Deaf Deaf Are you over 75 years old?The Department of Health has advised that all patients of 75 years 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.AllergiesDo you have any allergies? Yes No Please specify what you are allergic to, what happens and when you had your first reactionImmunisation HistoryPlease list any immunisations/vaccinations you have had OptionalPlease include dates Important Registration InformationWe are able to provide SystmOnline for ordering prescriptions, booking appointments and having access to your medical records. This system directly links into your records so you will also be able to do the following: Access your NHS Number View your address as documented on your records Request medication that is due and see your list of repeat medications including your pharmacy Book an appointment with your registered GP Cancel any appointments View your appointment history Update your records with your latest contact information Complete patient questionnaires. To be set up for SystmOnline please speak to a receptionist. You will be asked provide photo ID. These photo identification examples are acceptable: Driving Licence Passport Bus pass Work identification For SystmOnline access for children under 14 the child’s parent or guardian can request the password please note the access will be stopped when patient turns 14. They will then have to apply for their own password. SystmOnline also provides an application which is available on both Apple and Android devices. There is a dedicated help file available on there if you have any questions with how to use SystmOnline and there is a step by step guide available on our website. For any other quarries please get in touch with the surgery. Please note if you have any trouble with your login, there is a “I’ve Forgotten my Password” option available on the website. However, we cannot give passwords resets over the phone. From April 2019 GP practices are required to provide new patients with full access to their GP record from their registration date with the practice. To have access to this information please speak to one of the receptionist.SystmOnline Registration Form for full access to GP medical records from date of registration with the practice.Full Name Optional Date of Birth Day Optional Month Optional Year Optional Address Street Address Optional Address Line 2 Optional City Optional Postcode Optional Contact Number OptionalEmail Address Optional (You will be sent a verification email when this has been added to your records so that you can reset your own password without needing to contact the practice)Please provide at least 1 photo identification upon registering for this service. Optional Drop files here or Select files Max. file size: 50 MB. The following ID is acceptable: Passport, Driving License, Work ID, Bus PassPatients Online Access to Medical Records – Request formFull Name Optional Date of Birth Day Optional Month Optional Year Optional Address Street Address Optional Address Line 2 Optional City Optional Postcode Optional Please tick the appropriate for what you are requesting I am requesting access to Full Medical Records from birth/date of registration Optional I am requesting access to Detailed Coded Record from birth/date of registration Optional Please provide at least 1 photo identification upon registering for this service. Optional Drop files here or Select files Max. file size: 50 MB. Consent FormI have today been given the opportunity to discuss sharing of my patient record and have read and understood the leaflet “Your electronic patient record & the sharing of information” I understand that the same record is used to store information recorded by different members of the care teams who are currently involved in providing my care, including but not limited to doctors surgeries, district nurses, health visitors, physiotherapists, podiatrists, social care and child health. I understand that I will be asked to give consent by each care team before they are able to access or add to any shared data about me. I understand that I can change my decision at any time.Share-out I WOULD like the information recorded at Hill View & Farnsfield Surgery 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. Optional I WOULD NOT like the information recorded at Hill View & Farnsfield Surgery 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. Optional Share-in I WOULD like the information recorded at other care teams who are involved in my care to be seen by members of the team at Hill View & Farnsfield Surgery, where I have granted those care teams the right to add to my shared data. Optional 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 Hill View & Farnsfield Surgery, where I have granted those care teams the right to add to my shared data. Optional Full Name Optional Date Day Optional Month Optional Year Optional ORPatient representative Optional Relationship to patient Optional How we use your informationThis privacy notice explains why the GP Practice collects information about you, and how that information may be used. As data controllers, GPs have fair processing responsibilities under the Data Protection Act 1998. This means ensuring that your personal data are handled in ways that are transparent and that you would reasonably expect. The Health and Social Care Act 2012 changes the way that confidential data are processed it is important that you are made aware of these changes, understand that you can object to certain uses, and how to do so. The health care professionals who provide you with care maintain records about your health and treatment. These records may be electronic, paper, or both and various measures are employed to ensure the security of your records. The information contained in the records is used for your direct care and kept confidential. However, we may be required to disclose your personal information if it is required by law, is justified in the public interest, or you consent for the use for other purposes. Other reasons why your data may be disclosed are for use for statistical purposes where the information will not be able to identify you, or for research purposes for which your consent will be requested. Under the Health and Social Care Act 2012 the Health and Social Care Information Centre can request personal confidential information from your GP practice without asking for your consent first. On some occasions it may be necessary to undertake clinical audits of records to ensure that the best possible care has been provided to you or to prevent the spread of infectious disease, wherever possible this will be done in anonymised form. Your data may also be shared with other healthcare professionals who provide you with care through local integrated care services. Your permission to share your data between the services will be requested, although refusing permission may impact your care. If this is the case your doctor will be able to explain how this could affect your care. Your GP is encouraged to use a process called Risk Stratification to identify patients who may require additional care due to long term conditions. The information is used to help support patient care and prevent unnecessary hospital admissions. If you do not want your data used for these purposes you may object by contacting the practice who will explain how you can prevent your data being used in this way. We are committed to protecting your privacy and will only use data collected lawfully in accordance with the Data Protection Act 1998, Human Rights Act, the Common Law Duty of Confidentiality, and the NHS Codes of Confidentiality and Security. The only staff who have access to your data are those with a legitimate reason to do so, and is controlled by multiple levels of security. The Data Protection Act 1998 gives you the right to view or access information that the GP Practice holds about you. This is known as ‘the right of subject access’. Under this right you are entitled to have a description of the information, explanation of why it is held, who it could be disclosed to, and you are entitled to a copy of the information. If you would like to make a ‘subject access request’, please contact the practice manager in writing. If you would like further information about how your information is used by the GP Practice, please contact the practice manager, or view the Fair Processing Notice on the practice notice board or the practice website. The practice is registered as a data controller under the Data Protection Act 1998 – the registration number is and can be viewed online in the public register at How we use your information leafletNHS Organ Donor registrationFor more information on organ donation please visit: www.organdonation.nhs.ukNHS Blood Donor registrationIf 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 SignatureDeclaration I certify that the information I have provided is correct and consent to my personal and medical information being used as stated above. Optional Signature Your Full NameDate Day Month Year