New Patient Registration

 

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Please complete our online form

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Patient's Details

Information we need to register you with the practice
Please note all fields marked with a * are mandatory for your registration

Thank you for registering with us. We very much hope that the services and facilities that we are able to offer, will help towards a healthy future for you. Successful medical services are a two-way association and as part of your registration, we ask that you complete the questions below. We know that there is a lot to complete, but this information will be invaluable to us, to help us to meet your needs.

We also offer a New Patient Health Check to all newly registered patients. Your records may take several weeks to reach us and this Health Check allows us to start to build a picture of your health  needs.
Under 5s are looked after in conjunction with the Health Visiting Team.

Please bring a sample of urine with you, in a clean container
 
Ethnicity & Religion
Emergency Contact
Allergies
Previous Details
Please include postcode
If you are from abroad
Please use this date format: DD/MM/YYYY
If you are returning from abroad

Previously been registered with the NHS in the UK

Please use this date format: DD/MM/YYYY
Please use this date format: DD/MM/YYYY
Were you ever registered with an Armed Forces GP

Footnote: 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

Supplementary Questions

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 at reception. Alternatively for more information go to www.nhs.uk/nhs-services/visiting-or-moving-to-england

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.

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.

European Economic Area (EEA) Country

For a list of EEA countries visit: www.gov.uk/eu-eea

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 of the GP practice, including at a hospital.

Please enter the details from your EHIC or PRC below.

S1 Form

Please give your S1 form to the practice staff.

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 The Department for Work and Pensions for the purpose of recovering your NHS costs from your home country.

Carers

At Tisbury Surgery, we aim to support carers in whatever ways we can.

A carer is someone who provides help for someone, who would not be able to manage on a day to day basis, without that help.

Is there someone who relies on you so much that you would need to organise backup if you went away for a day or two? If so, then you are a carer.

It could be a neighbour, a friend or a family member. Carers play a vital role in our community and we like to know who they are so that we can keep them updated about activities, local carers’ events, and put them in touch with other agencies who can offer them support.

We have a practice lead who co-ordinates all our carers’ activities and who can arrange Carers’ Assessments, should you choose.

Please complete the section below, if you are a carer for someone and we will be in touch with you shortly.

SMS Messaging

SMS Messaging

We offer an extra service of SMS Messaging to patients.

This is used to confirm appointments, to send messages about test results, inform you of upcoming health campaigns etc.

However, there are certain conditions attached to use of the service.

Please read the statement below and, should you wish to register for SMS Messaging, compete and sign the declaration at the bottom.

Mobile Phone Number: 

  
 
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Home Circumstances
Lifestyle

Adults should:

  • Aim to be physically active every day. Any activity is better than none, and more is better still
  • Do strengthening activities that work all the major muscles (legs, hips, back, abdomen, chest, shoulders and arms) on at least 2 days a week
  • Do at least 150 minutes of moderate intensity activity a week or 75 minutes of vigorous intensity activity a week
  • Reduce time spent sitting or lying down and break up long periods of not moving with some activity.

You can get more information about the benefit of exercise on the NHS Website.

Your Personal Alcohol Consumption

alcohol consumption Image 1 unit

Audit Score Result

you have a score of 

If you are drinking less than 14 units of alcohol per week, then your drinking is within the UK Chief Medical Officers' low risk drinking guidelines.

But if you are drinking regularly at or above the low risk guidelines of 14 units a week, or, you are drinking six or more units - if you are female - or eight or more units - if you are male - in one single session (binge drinking), please consider the increased serious risks to your health being caused by your current drinking pattern.

Depending on your score, one of the Practice Team may be in touch with you You can get more information about the risks of excessive drinking on the NHS Website.

 
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Adult Females
Please use this date format: DD/MM/YYYY.
Immunisation History
Please include dates.
Medical History
Please include dates.
Please include dates.
Please include dates.

Over 75 years old?

The Department of Health has advised that all patients of 75years 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.

 
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Summary Care Record

Summary Care Record (SCR)

The Summary Care Record (SCR) system is designed to help both your GP and any emergency staff you contact when the surgery is closed to treat your health needs more efficiently.

Your information will be shared between your GP practice, our local hospital and Out Of Hours service. This will enable your GP surgery to access results and any visits you have at the hospital quickly and efficiently, but it also means that if you have an emergency and contact the Out Of Hours service or visit A&E they will have access to your current medications as well as allergies and are better able to treat you.

If you do not return this form, a Summary Care Record will be created for you based on implied consent

SystmOnline

SystmOnline

SystmOnline is a website which allows you to do things such a booking telephone appointments, cancelling appointments, ordering repeat prescriptions online, viewing parts of your medical records. There are two different types of access available to you.

Learn more about SystmOnline

Please confirm the following statements

Type 1 Opt-out

The data held in your GP medical records is shared with other healthcare professionals for the purposes of your individual care. It is also shared with other organisations to support health and care planning and research.

If you do not want your personally identifiable patient data to be shared outside of your GP practice for purposes except your own care, you can register an opt-out with your GP practice. This is known as a Type 1 Opt-out.

Type 1 Opt-outs may be discontinued in the future. If this happens then they may be turned into a National Data Opt-out. Your GP practice will tell you if this is going to happen and if you need to do anything. More information about the National Data Opt Out

You can use this form to:

  • Register a Type 1 Opt-out, for yourself or for a dependent (if you are the parent or legal guardian of the patient) (to Opt-out)
  • withdraw an existing Type 1 Opt-out, for yourself or a dependent (if you are the parent or legal guardian of the patient) if you have changed your preference ( to Opt-in )

This decision will not affect individual care and you can change your choice at any time, using this form.

Type 2 Opt-out

All health and care organisations in England are required to apply your national data opt-out in line with the policy by March 2020, including hospitals and GP practices. Your type 2 opt-out only applied to confidential patient information being shared by NHS Digital.

National data opt-outs are not recorded at the GP practice and instead you can change your national data opt-out using the online service or by calling our contact centre.
Young adults from the age of 13 can set and change their own national data opt-out.

 
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Identification Upload

Patient Identification

To fully register you at the practice, we need Two forms of Acceptable ID (if not possible, please let us know).

We will not store these documents and we will securely delete / destroy them after our initial verification.

OPTIONAL: Photo of your face to add to your records to help us identify you (if you agree)

Acceptable Identification: Photo Driving License, Passport, Tenancy agreement, Mortgage statement, Bank statement, Utility bill (date within the past 3 months) etc.

Communication Needs
Hard of hearing, need a translation service, learning difficulties, etc.
Tick as many as necessary
 
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NHS Organ Donor registration

For more information on organ donation please visit: www.organdonation.nhs.uk

NHS Blood Donor registration

If 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

What happens to my information?

Personal and medical information about patients registered at this practice are primarily kept electronically, although some is kept in paper form. Some information will be sent to hospital consultants and other health professionals to whom you are referred by your GP in order to provide continued healthcare and obtain treatment for you.

We sometimes use accredited suppliers for our communication with you, for example when we send recall letters for review clinics or medication reviews. All suppliers we use are checked carefully to ensure they comply with strict confidentiality protocols.

To ensure the security of all patient information, all staff that has access to your records is covered by confidentiality clauses in their contracts and the Data Protection Act and the Freedom of Information Act. Our guiding principle is that we hold your records in strict confidence.

I certify that the information I have provided is correct and consent to my personal and medical information being used as stated above.

Privacy Consent

This form collects personal and medical information about you. We use this information to allow the practice team to contact you. Please read our Privacy Policy to discover how we protect and manage your submitted data.

 
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