New Patient Registration Form ( GMS1) and Health Questionnaire

Fields marked "REQUIRED" are compulsory. 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. Your details will be held at the surgery for a limited period of time. You are required to present in person to sign your registration form and provide proof of your address. Sending this form does NOT guarantee or even imply that you will be accepted onto the practice register.

Last Updated: 14/02/2022

Patient Registration ( GMS1) section:

Yor details

Title

I am a student at:

Surname *

First Name (s) *

Previous Surname *

Birth town *

birth country *

Date of Birth *

NHS Number

Gender *

Male

Female

Indeterminate

Unspecified - rather not say

Address *

Postcode *

Home Number *

Mobile Number

Can we send you text messages (SMS)? e.g APPOINTMENT REMINDERS, PRACTICE NEWS, ADVICE ABOUT your HEALTH *

I consent to receive text messages (SMS)

I do not consent to receive text messages (SMS)

Email Address

Can we send you e-mails? e.g APPOINTMENT REMINDERS, PRACTICE NEWS, ADVICE ABOUT your HEALTH *

I consent to receive e-mails

I do not consent to receive e-mails

Please help us trace your previous medical records by providing the following

YOUR PREVIOUS ADDRESS IN UK

NAME OF PREVIOUS GP WHILE AT PREVIOUS ADDRESS

ADDRESS OF THAT DOCTOR

If you are from abroad

YOUR FIRST UK ADDRESS WHERE REGISTERED WITH A GP

IF PREVIOUSLY RESIDENT IN UK, DATE OF LEAVING

DATE YOU FIRST CAME TO LIVE IN UK

If you are returning from the armed forces

ADDRESS BEFORE ENLISTING

SERVICE/PERSONNEL NO.

ENLISTMENT DATE

Complete Registration

IF YOU ARE REGISTERING A CHILD UNDER 5

I wish the child above to be registered with the named doctor for Child Health Surveillance

IF YOU NEED YOUR DOCTOR TO DISPENSE MEDICINES AND APPLIANCES

I live more than 1 mile in a straight line from the nearest chemist

I would have serious difficulty in getting them from a chemist

NHS Organ Donor Registration

I want to register my details on the NHS Organ Donor Register as someone whose organs/tissue may be used for transplantation after my death. For more information, please ask for the leaflet on joining the NHS Organ Donor Register

PLEASE TICK THE BOXES THAT APPLY:

Any of my organs and tissue or

Kidney

Heart

Liver

Corneas

Lungs

Pancreas

Any part of my body

SIGNATURE CONFIRMING CONSENT TO ORGAN DONATION

Date

NHS Blood Donor Registration

For more information, please ask for the leaflet on joining the NHS Blood Donor Register

I WOULD LIKE TO JOIN THE NHS BLOOD DONOR REGISTER AS SOMEONE WHO MAY BE CONTACTED AND WOULD BE PREPARED TO DONATE BLOOD.

Tick here if you have given blood in the last 3 years

SIGNATURE CONFIRMING CONSENT TO INCLUSION ON THE NHS BLOOD DONOR REGISTER

date

PREFERRED ADDRESS FOR DONATION: (IF DIFFERENT FROM ABOVE, E.G. PLACE OF WORK)

POSTCODE

SUPPLEMENTARY QUESTIONS | PATIENT DECLARATION for all patients 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 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 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. 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.

PLEASE TICK ONE OF THE FOLLOWING BOXES: *

I understand that I may need to pay for NHS treatment outside of the GP practice

I understand I have a valid exemption from paying for NHS treatment outside of the GP practice. This includes for example, an EHIC, or payment of the Immigration Health Charge ('the Surcharge'), when accompanied by a valid visa. I can provide documents to support this when requested

I do not know my chargeable status

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 *

Yes, I declare

Are you a parent or guardian, filling out this form on behalf of a child under 16?

Yes No

If yes, NAME of PARENT OR GUARDIAn

RELATIONSHIP TO PATIENT:

SIGNED

date

NON-UK EUROPEAN HEALTH INSURANCE CARD (EHIC), PROVISIONAL REPLACEMENT CERTIFICATE (PRC) DETAILS and S1 FORMS

Complete this section if you live in an EEA 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 this section if you have an EHIC issued by the UK. 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 the GP practice, including at hospital).

DO YOU HAVE A NON-UK EHIC OR PRC?

Yes No

IF YES, PLEASE ENTER DETAILS FROM YOUR EHIC OR PRC BELOW:

COUNTRY CODE

full NAME:

Date of birth

PERSONAL IDENTIFICATION NUMBER

IDENTIFICATION NUMBER OF THE INSTITUTION:

IDENTIFICATION NUMBER OF THE CARD

EXPIRY DATE:

PRC VALIDITY PERIOD

14. PLEASE TICK IF YOU HAVE AN S1 (E.G. YOU ARE RETIRING TO THE UK OR YOU HAVE BEEN POSTED HERE BY YOUR EMPLOYER FOR WORK OR YOU LIVE IN THE UK BUT WORK IN ANOTHER EEA MEMBER STATE). PLEASE GIVE YOUR S1 FORM TO THE PRACTICE STAFF

I have an S1 form

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.

Online access

Would you like to have Online access to appointment booking, Ordering repeat prescriptions and certain details of health records?

Yes No

If yes, please go to : https://www.petworthsurgery.co.uk/online-services-3 for more information and to sign up

Patient Participation Group

The Practice is committed to improving the services we provide to our patients. To do this, it is vital that we hear from people about their experiences, views, and ideas for making services better. By expressing your interest, you will be helping us to plan ways of involving patients that suit you. It will also mean we can keep you informed of opportunities to give your views and up to date with developments within the Practice. If you are interested in getting involved, please let us know.

are you interested in getting involved?

Yes, I am interested in becoming involved in the Practice Patient Participation Group

No, Thank you

Summary Care Record ( SCR)

Patients in England have a Summary Care Record. The basic Summary Care Record is an electronic record of important patient information such as medication you’re on and what you’re allergic to. This is held centrally by the NHS and can only be accessed by authorised healthcare staff. There is now an option to add “Additional Information” to your Summary Care Record. This makes the Summary Care Record a much more useful source of information for departments like A&E and the Ambulance service if they need to treat you in an emergency. The information that will be included in your Summary Care Record if you choose to add it is:  Significant medical history (past and present)  Reasons for medication  Anticipatory care information (such as information about the management of long term conditions)  Communication preferences  End of life care information  Immunisations A full list of the terms that will be included in this additional information is available here: https://digital.nhs.uk/services/summary-care-records-scr/additional-information-in-scr/additional-information-research-project-report/what-summary-care-records-are Specific sensitive information like fertility treatments, sexually transmitted infections, pregnancy terminations and gender reassignment will not be automatically included when the information is added. If there are any particular items that you would like to be either included or excluded from your Summary Care Record, your GP surgery can mark these items for you in your health record.

Are you happy to have a Summary Care Record? *

Yes, basic one - for medications, allergies and adverse reactions

Yes, the additional one - for medications, allergies and adverse reactions and additional information

No, I dissent . I don't want a Summary Care Record

Sharing Your Medical Record

This Data sharing allows NHS organisations who are caring for you (e.g. hospitals, specialist consultants, or the community Nurses) to see your health record and / or record data which in turn your GP will able to see on our end. (Provided, their computer system supports this). Petworth Surgery allows data sharing as a default option with local NHS Care providers. It’s important to note that this is not something people can just look at, they need to be actively caring for you. Should any other NHS care provider require access to your shared record, they must seek permission to view the record. For example: If you need a visit from one of the community nurses, they will be able to see your health record and they are also able to add information to your record, so your GP can have a better overview of your care. However if, let’s say, you are on holiday in Cornwall and you injure yourself and end up at the A&E of the local hospital they will have ask your permission (permission to view) to access your record for the period of time they actively provide care for you. The only exception to the “permission to view” is if you are unable to give consent for some reason, such as being unconscious, and a member of staff deems it medically necessary to access your record. In this case, they can perform an override to access you notes, but they must state the reason why they are doing it. When this happens, an alert is also generated for the appropriate Caldicott Guardians to check that the access was appropriate. Also it may be necessary to share data held in GP practices with, let's say, the district nurses but the local podiatry department would not need to see it to undertake their work. In this case, we will allow the podiatry department to share data they record, for you, with us, but they will not be able to see any part of your record held by the surgery. patients would allow the surgery to share their data. If there are particular parts of your record that you would like to remain private, but you are happy to share the rest, then just inform your GP surgery of which items you would like to be private and they can mark them as so. If you don’t want this sharing option to be enabled please let your surgery know so they can opt you out. You can always change your mind.

Do you consent for your health record to be shared with (be visible to) other NHS organisations at which you receive care? (E.g. hospital. Community nurses etc.) *

Yes No

Next of Kin

Please give name, address, telephone number and relationship of next of kin *

Have you nominated someone to speak on your behalf? (e.g. a person who has Power of Attorney , next of kin, family members )) *

Yes No

If 'yes' please give their name, address, and telephone number

Will

Do you hold a Living Will? *

Yes No

If 'yes, please provide us with a copy

Do Not Attempt Cardiopulmonary Resuscitation Decision

Do you have a DNACRP form in place? (Do Not Attempt Cardiopulmonary Resuscitation Decision Form) *

Yes No

If yes, Please bring - email a copy to us.

Proof of Identity and Address Provided

Identity Document Type *

Birth Certificate

Driving Licence

Passport

Utility Bill

Allowance Book

Solicitors Letter

Offer of Tenancy

Other

Health Questionnaire

Information About You

Specific needs:

Please detail below any specific needs you have so the Practice cab ensure they are identified and accommodated by taking the appropriate action

Please state any Sensory Impairment you have (i.e Speech, Hearing, Sight);

Do you have any special requirements to communicate with us?(e.g Braille or Large print) if 'yes' please specify:

Please state any physical disabilities you have

Please state any mental disabilities you have

Please state any requirements you have to be able to access the Practice premises

Please state any Religious or Cultural needs

Do you require the help of a Translator / Interpreter?

Yes No

If 'yes' what language?

Please state any allergies and sensitivities you have

Please state any phobias you have

Medical Information

Immunisations

Carers

Do you have a carer? *

Yes No

If yes please give details

Are you a carer? *

Yes No

(If yes please give details)

Women

If you use contraception - What method?

Contarceptive pill

Coil

Implant

Have you ever had a cervical smear? *

Yes No

Do you have any children?

Yes No

If 'yes' what are their ages?

When was your last mammogram?

If 'yes', please state when, where and the result

Smoking

Do you smoke? *

Smoker

Non- smoker ( never smoked)

Ex-smoker

VAPER

If ex-smoker , when did you stop? *

If you do currently smoke, how many cigarettes or ounces of tobacco do you smoke per week? *

Would you like advice on giving up smoking? *

Yes No

Alcohol

MEN: How often do you have EIGHT or more drinks on one occasion? WOMEN: How often do you have SIX or more drinks on one occasion? *

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

In the last year has a relative or friend, or a doctor or other health worker been concerned about your drinking or suggested you cut down? *

Exercise

How often do you exercise?

Daily

Few times a week

Few times a month

Never

What exercise do you do?

Family History

Please state any serious illness, in particular cancer, heart disease, stroke, high blood pressure, diabetes or any inherited disease. Please state your relationship to the individual and in the case of cancer, the type of cancer. *

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

Have you had a flu vaccination? Enter date or 'never': *

Have you had a pneumococcal vaccination? Enter date or 'never' *

Signature

Signed *

Signature *

Signature of patient

Signature on behalf of patient

Date *

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