New Patient Registration Form - Adult - Rowlands Road Surgery

Please complete all sections in full.

Last Updated: 02/05/2023

Contact Details

* It is your responsibility to keep us updated with any changes to your telephone number, email & postal address. We may contact you with appointment details, test results, health campaigns or Patient Participation Group details If you do not consent to being contacted by SMS or Email, please tick here: *

SMS

GENDER - please state male/female/other (please specify) below: *

NHS Number *

Full Name *

Previous Surname(s) if applicable *

Address *

Previous Address *

Date of Birth *

Home Telephone *

Mobile Telephone *

I consent to be contacted by SMS on this mobile number *

Yes No

Next of Kin - enter Name, Contact Number and Relationship *

Family members registered with us - enter full name and date of birth *

Has the patient been registered in the UK before? If no, please state date entered the UK *

Other Details

Previous GP - Name and Address *

Country of Birth *

Ethnicity *

Religion *

Housing *

Employment *

Overseas Visitor

Yes

European Health Insurance Card held (please bring details to surgery)

Armed Forces

Military Veteran

Family member

Communication Needs

What is your main spoken language? *

Do you need an interpreter? *

Yes No

Do you have any communication needs? If yes, please specify: *

Do you have a Learning Disability? If yes, please request a Learning Disability Screening Tool form *

Yes No

Carer Details

Are you a Carer? *

Do you have a Carer? If yes, enter full name, contact number and relationship (we will only add carer's details if they give their consent to have these details stored on your medical record) *

Medical History

Family History

Allergies

Please record any allergies or sensitivities below *

Current Medication

Please check and include as much information about your current medication below Please give us your previous repeat medication list if possible and a medication review appointment may be needed *

Your Lifestyle

Please answer the following questions which are validated as screening tools for alcohol use. Add up your score to each question.

How often do you have a drink containing alcohol? *

Enter your score *

A score of less than 5 indicates lower risk drinking. Scores of 5 or more requires the following 7 questions to be completed. Add up your score to each question.

How often during the last year have you found that you were not able to stop drinking once you had started?

How often during the last year have you failed to do what was normally expected from you because of your drinking?

How often during the last year have you needed an alcoholic drink in the morning to get yourself going after a heavy drinking session?

How often during the last year have you had a feeling of guilt or remorse after drinking?

How often during the last year have you been unable to remember what happened the night before because you had been drinking?

Have you or somebody else been injured as a result of your drinking?

Has a relative or friend, doctor or other health worker been concerned about your drinking or suggested that you cut down?

Your Lifestyle - continued

Do you smoke? *

Never smoked

Ex-smoker

Yes

Do you use an e-Cigarette? *

How many cigarettes did/do you smoke a day? *

Would you like help to quit smoking? For further information, please see: www.nhs.uk/smokefree *

Yes No

Height *

Weight *

Waist Circumference *

Women Only - Do you use any contraception? (If needed, please book appointment)

Yes No

Women Only - Do you have a coil or implant in situ? Enter yes/no - if yes, add date inserted

Women Only - Are you currently pregnant or think you may be? Enter yes/no - if yes, add expected due date

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 www.nhs.uk/Livewell/Studenthealth

I am less than 24 years old and have had two doses of the MMR Vaccination

I am less than 25 years old and have had a Meningitis C Vaccination

Further Details

You are entitled to make an appointment to see any GP of your choice (subject to availability) however the Named Accountable GP who has overall responsibility for your care is: *

If you would like your prescriptions to be sent electronically, please provide details of the pharmacy you would like to use: *

We are committed to improving the services we provide. The Patient Participation Group is a mechanism for us to gain valuable feedback from our patients about their experiences, views and ideas for improving our services. Would you like to be involved in our Patient Participation Group? *

Yes No

Blood Donation *

Organ Donation

You will automatically be considered that you agree to become an organ donor when you die unless you are under 18, have opted out or are in an excluded group. For further information, please see: www.organdonation.nhs.uk

Signature

I confirm that the information I have provided is true to the best of my knowledge (for either myself or on behalf of the patient as appropriate) *

Your Name *

Date *

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?

Rowlands Road Surgery 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: www.nhs.uk/NHSEngland/thenhs/records

For further information about how the NHS uses your data for research & planning and to opt-out, please see: www.nhs.uk/your-nhs-data-matters

Do you consent to your GP Practice sharing your health record with other organisations who care for you? *

Do you consent to your GP Practice viewing your health record from other organisations that care for you? *

Your Summary Care Record (SCR) Do you consent to having an Enhanced Summary Care Record with Additional Information? *

I can confirm the above information in regards to sharing my health record is correct *

Yes

Online Access to your Health Record

What is your email address? *

I wish to have online access to:

I wish to access my medical record and understand and agree with each statement: Please tick all that apply

Please bring Photo Proof of ID e.g. Passport, Photo Driving License or Photo ID card and Proof of Address e.g. Bank statement, Utility Bill or Council Tax from within the last 3 months in order for the sign up process to be completed

Signatures

Your Name *

Date *

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New Patient Registration Form - Adult - Rowlands Road Surgery

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