New Patient Registration - Updated January 2022

Last Updated: 16/03/2022

NEW PATIENT REGISTRATION FORM

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.  Sending this form does NOT guarantee or even imply that you will be accepted onto the practice register.












PLEASE HELP US TRACE YOUR PREVIOUS MEDICAL RECORDS BY PROVIDING THE FOLLOWING INFORMATION:




IF YOU ARE FROM ABROAD




Were you ever registered with an Armed Forces GP

These questions are optional and your answers will not affect your entitlement to register or receive services from the NHS but may improve access to some NHS priority and service charities services.






IF YOU NEED YOUR DOCTOR TO DISPENSE MEDICINES AND APPLIANCES


SIGNATURE AND DECLARATION

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.

A parent/guardian should complete the form on behalf of a child under 16






NHS England use only



To be completed by the GP Practice







SUPPLEMENTARY QUESTIONS: - These questions and the patient declaration are optional and your answers will not affect your entitlement to register or receive services from your GP

PATIENT DECLARATION - for all patiens 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 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 disease and any treatment of those diseases are free of charge to all people, while some groups who are oridinarily 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, regardless of advance payment.

The information you give on this form will be used to assist in identiying 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 contact on behalf of the NHS to confirm any details you have provided.


SIGNATURE

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.

A parent/guardian should complete the form on behalf of a child under 16.






Non UK European Health Insurance Cared (EHIS), Provisional Replacement Certificate (PRC) details and S1 forms.

Complete this section if you live in an EU 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 ths section if you  have an EHIC issued by the UK.













How will your EHIC/PRC/S1 data be used

By using your EHIC or PRC for NHS treatment costs your EHIc or PRC data and GP appointment data will be shared with NHS secondary care (hospitals) and NHS digital solely for the purposes of cost recovery.  Your clinical data will not be shared in the cost recovery process.  Your EHIC, PRC or S1 information will be shared with Business Service Authority for the purpose of recovering your NHS costs from your home country

NEW PATIENT QUESTIONNAIRE

Please complete the following questionaire about your medical history.

YOUR CONTACT DETAILS




















PREVIOUS GP


PROOF OF IDENTITY AND ADDRESS PROVIDED


CONTACTING YOU


NEXT OF KIN


CARERS





SMOKING





ALCOHOL

Please help us by answering the three questions below:  If you score 5 or more then please answer the additional questions below.

Scoring:

Please calculate your total score:……………………………………………………………………….

If your score is less than 5 then there are no more alcohol related questions.  Please go to ‘Your Health Continued’ Section on Page 5

A total of 5 or more indicates increasing or higher risk drinking.

 

 




ALCOHOL CONTINUED

If your score is 5 or more then please complete the additional questions.

Please calculate your total score: ............................................................

0-7     Lower risk

8-15    Increasing risk

16-19  Higher risk

20+     Possible dependence







MEDICAL INFORMATION






















FAMILY HISTORY


WOMEN



WILL


For patients aged 65 and over or those with a chronic disease (e.g. asthma or diabetes)



ONLINE SERVICES

For anyone aged 16 and over we offer online services for appointment booking and repeat prescription ordering. This is the quickest & easiest way to order your medication.

We will need to see 2 forms of ID to be able to register you for online services, preferably 1 photo and 1 with proof of your current address (within 3 months).

Once registered, you will also be able to view your summary record, detailing current medication, allergies and vaccinations.

If you decide not to use online services you will need to bring your prescription request into the surgery as we are unable to accept either telephone or pharmacy requests.

For further information on GP online services go to:     www.nhs.uk/GPonlineservices

 




PROXY ACCESS

If you are aged 16 or over you can nominate another person (called a ‘proxy’) to have access to your online Services (this is called proxy access). This will allow the nominated person to access your on-line account to book appointments and order prescriptions. You can choose to end this access at any time after it has been granted.  ID checks would need to be done on the nominated proxy.

If you would like to nominate a person to have proxy access, please ask at reception for an application form.

ACCESS TO YOUR MEDICAL RECORDS

If you would like online access to your medical record you can apply for this by requesting an application form from reception or by downloading one from the practice website. This access is subject to an authorisation process and can take up to 20 working days to complete once your application has been received.   You will need to provide 2 forms of ID (including 1 photographic) on application, which need to be done in person.

YOUR MEDICAL INFORMATION - SHARING YOUR DATA

Under the General Data Protection Regulations (GDPR), we have a responsibility to keep your medical records confidential. We need your consent to share this with other authorised health professionals involved in your care or planning your care. More information is available on the website or the number below.

Please see the Privacy Notice on our website for more information on how your data is held and used by the practice. www.thespasurgery.co.uk




YOUR DATA MATTERS: (www.nhs.uk/your-nhs-data-matters Tel: 0300 303 5678

The NHS wants to make sure you and your family has the best care now and in the future. Your health and adult social care information supports your individual care. It also helps us to research, plan and improve health and care services in England.

There are very strict rules on how this data can and cannot be used, and you have clear data rights. We are committed to keeping patient information safe and will always be clear on how it is used.

You can choose whether or not your confidential patient information is used for research and planning.

If you do not wish your information to be used in this way please opt-out by visiting the

website www.nhs.uk/your-nhs-data-matters or calling 0300 303 5678. The practice is unable to record this for you.

 

SIGNATURE