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Welcome to Elgar House Surgery.Please complete the enclosed New Patient Questionnaire and Registration Form. Until this is completed you will not be registered at the Practice.PLEASE NOTE IF YOU DO NOT ATTEND YOUR FIRST APPOINTMENT, YOU WILL BE ADVISED TO REGISTER AT ANOTHER PRACTICE, AND REMOVED FROM OUR PRACTIVE LIST.In this pack you will find:New patient questionnaire and registration formConsent to online access formInformation about texts and emailsSummary care record opt out formInformation about our Patient Participation Group Our latest newsletterPatient LeafletIt is very valuable for us to get some information before we receive your records from your previous GP, as this can take many weeks. We can also make sure that medical problems are followed up and repeat prescriptions are organized.Named GPAll patients now have a named GP. This doctor will have overall responsibility for the care and support that our surgery provides to you. This does not prevent you from seeing other GPs in the practice. You can still book to see/speak to any of the GPs, and your “named GP” might not always be available to see you. Registration for organ and blood donation Registration for organ and blood donation is no longer part of your registration process with the surgery. Therefore patients are requested to self-register on the NHS Blood and Transplant website?nhsbt.nhs.uk and by doing so you have a greater choice and options. If you prefer to talk to someone to register you can telephone the NHS Blood and Transport helpdesk on 0300 123 2323.Identifying Patients with Disabilities and other needsIt is important to us to be able to identify and record patient’s requirements in their medical notes if they have a recorded disability. There is a section on the new patient questionnaire. Please complete if you are registered blind or partially sighted, registered deaf, registered deafblind, on the learning disabilities register, have a visual impairment, have hearing difficulties or impairments or those who use hearing aids.Electronic Prescription ServiceThe Electronic Prescription Service (EPS) is an NHS service. It gives you the chance to change how your GP sends your prescription to the place you choose to get your medicines or appliances from. If you normally collect your repeat prescriptions from your GP you will not have to visit your GP practice to pick up your paper prescription. Instead, your GP will send it electronically to the place you choose, saving you time. You will have more choice about where to get your medicines from because they can be collected from a pharmacy near to where you live or work. For more information please visit your chosen pharmacy or see .uk/epspatients. If you use an appliance contractor please speak to reception regarding this nomination. If you use an appliance contractor you will need to speak to them to ensure they are aware we are your new surgery.National Data Opt-OutThe NHS is committed to keeping patient information safe and always being clear about how it is used.Your health and care information is used to improve your individual care. It is also used to help us research new treatments, decide where to put GP clinics and plan for the number of doctors and nurses in your local hospital. Wherever possible we try to use data that does not identify you, but sometimes it is necessary to use your confidential patient information.If you wish to find out more or to opt out please visit nhs.uk/your-nhs-data-matters?or telephone 0300 303 5678All information provided is strictly confidential and will be processed using the Practice’s Patient Confidentiality / Data Protection protocolsELGAR HOUSE SURGERYNEW PATIENT QUESTIONNAIRE AND REGISTRATION FORMTaken By/ID Verified?Date:Named GP AllocatedGMS1 completed (if from overseas):Emis:Entered By:Personal Details: Your Contact number:TitleSurnameForenameMiddle Name(s)Date of BirthNHS NumberGenderMarital StatusPrevious Surname(s) (where applicable)Town & Country of BirthDate First came to live in UKEthnicity FORMCHECKBOX White/British FORMCHECKBOX Pakistani/British Pakistani FORMCHECKBOX Black/ Black British African FORMCHECKBOX Mixed White/Black Caribbean FORMCHECKBOX Irish/white Irish FORMCHECKBOX Bangladeshi/ British Bangladeshi FORMCHECKBOX Black/ Black British Caribbean FORMCHECKBOX Chinese FORMCHECKBOX White Other Background FORMCHECKBOX Asian/ Asian British Other FORMCHECKBOX Black/ Black British Other FORMCHECKBOX Other FORMCHECKBOX Indian/British Indian FORMCHECKBOX Mixed White/Black Asian FORMCHECKBOX Mixed White/Black African………………………………….Main LanguageInterpreter Required? FORMCHECKBOX Yes FORMCHECKBOX NoHome Address:House Name\Flat NumberNumber & StreetLocalityTownCountyPostcodeContact Details:Home TelephoneMobile TelephoneWork TelephoneEmail AddressPatient Contacts:Next of Kin/Full Name & TitleRelationshipTelephone NumberPatient here(?) Yes/NoPlease help us trace your previous medical records by providing the following:Previous address in the UKName and Address of previous GPIf you are from Abroad:Your first UK address where registered with a GPIf previously resident in UK; date of leavinghave you ever served in the Armed Forces:Enlistment DateDate of leavingService or Personnel NumberMedical History:Do you have any Medication Allergies? FORMCHECKBOX Yes FORMCHECKBOX NoIf Yes please state:Ladies: Are you currently Pregnant? FORMCHECKBOX Yes FORMCHECKBOX NoIf you are pregnant please provide estimated delivery date:Have you had a smear test? If so when? Are you a smoker? Yes/NoIf yes how many cigarettes do you smoke on average a day?......................Have you been a smoker in the past? Yes/NoIf yes, when did you cease smoking?...............................Drinking: Please complete the following questionsHow often do you have a drink containing alcohol?NeverMonthly or less2 – 3 times per month2 to 3 times per week4 + times per weekHow many units of alcohol do you drink on a typical day when you are drinking?1 -23 - 45 - 67 - 910+Carers: If you are a Carer please ask the receptionist for a yellow carers registration card. You will be added to the Practice RegisterIdentifying Patients with Disabilities and other needs - Are you: registered blind FORMCHECKBOX partially sighted FORMCHECKBOX registered deaf FORMCHECKBOX registered deafblind FORMCHECKBOX on the learning disabilities register FORMCHECKBOX have a visual impairment FORMCHECKBOX have hearing difficulties FORMCHECKBOX or use a hearing aids FORMCHECKBOX Do you have any information or communication needs when attending the surgery or receiving calls and letters from us?Are you happy for these requirements to be shared with other healthcare professionals? Yes FORMCHECKBOX No FORMCHECKBOX Signed:Date:Should you require any further information about the Practice please refer to the Practice Website: elgarhousesurgery.co.uk or speak to Reception.Reception Only:Seen by:Named GPElgar House Consent for Online Access to Medical RecordsPatients FormYou can now view your GP medical record online. If you would like to have secure online access to your records, we need to make sure that you understand what this involves and that you are happy for us to use the information about you (provided below) to set up and operate the service. The following form will take you through the things you need to think about. By signing the form you will be giving us your permission to go ahead with setting up the service for you. If you decide not to join, or wish to withdraw, it will not affect your treatment in any way. I agree to my GP practice giving me access to my record online.I agree to use the system in a responsible manner in accordance with all instructions given to me by the practice. If not access may be withdrawn.If I see information which does not relate to me, I will immediately log out and report the matter to the practice as soon as possible.I agree that it is my responsibility to keep secure, my username and passwords. If I think these have been shared inappropriately I will reset them using the instructions supplied. I am also responsible for keeping safe any information I may print from the record.I agree that my details below may be used to contact me about how useful I find the service and whether it could be improved.I understand that online access is granted at the discretion of the practice, taking into account my best interests. I will be informed of any decision to withdraw the service. Please note this does not affect your rights of Subject Access under the Data Protection Act.Other considerationsThe practice makes every effort to record information as accurately as possible, however there may be information that you do not feel is correct. A. If I notice any inaccuracies with my record, I will inform a senior member of staff or the practice manager as soon as possible of any errors or omissions.B. I understand that I may see information on my record that I was unaware of / have forgotten about that could cause distress.C. I understand that as before, I will be informed directly, by the practice, of any test results which require further action. However I understand that I may see these results online before the practice has been able to contact me. This could be while the surgery is closed and there is no one available to discuss them with me.Please retain this form for your information.Please remember to keep all your account details secure. If you think your account details may have been shared with someone you should reset them straight away. If you have any queries or concerns about the service or wish to withdraw from the service please speak to a senior member of staff or the practice manager. Elgar HouseConsent for Online Access to Medical RecordsPractice FormPatient DetailsSurnameFirst Name(s)Date of BirthNHS number (if known)AddressPost CodeTelephone NumberMobile NumberEmail**This should not be a shared address as we will use it to send you confidential information about your account/the service used.Please bring photographic ID with you - passport or driving license.? (If you do not have photo ID we may accept 2 current utility bills showing your name and address.)I have read and understand the information given above.To be signed at reception by patient ………………………………..……………..….Date …………………………For practice use only:ID checked documents……………………………….........................................Address and contact details complete ................................................Staff member signature ...................................................................... Date ........................... Medical Records Activated: Staff member signature ...................................................................... Date ...............................Text MessagesWe can now send you appointment confirmation messages and reminders by text message. If you wish to receive these text messages, please read the disclaimer below then complete and sign the slip below. Return it to the surgery. I consent to Elgar House Surgery contacting me by text message for the purposes of health promotion and for appointment reminders.I acknowledge that appointment reminders by text are an additional service and that these may not take place on all occasions, and that the responsibility of attending appointments or cancelling them still rests with me. I can cancel the text message facility at any time.Text messages are generated using a secure facility. I understand that they are transmitted over a public network onto a personal telephone and as such may not be secure. However, the practice will not transmit any information which would enable an individual to be identified.I agree to advise the practice if my mobile number changes or if this is no longer in my possession.Name………………………………………………..Date of birth………………….Mobile Number…………………………………….Signed………………………………………………Date………………………….For office use only: Date rec’d……………………. Date actioned …………….. …. Initials………..EmailWe are also planning to start sending letters via email. These will include letters inviting patients to clinics and appointments at the surgery, patient newsletters and other similar letters.If you wish to receive letters via email in the future, please complete and sign the slip at the bottom of the page and return it to the surgery.I consent to Elgar House Surgery sending me letters via email.Emails are sent through the NHS email service. I understand that they are sent via a public network to a personal email address and as such may not be secure.I agree to advise the practice if my email address changes.Name…………………………………………………….Date of birth……………………Email address………………………………………….Signed…………………………………………………Date…………………………….For office use only: Date rec’d……………………. Date actioned …………….. …. Initials……………PLEASE COMPLETE THIS FORM ONLY IF YOU FULLY UNDERSTAND THE CONTENTSWhat is the Summary Care Record?Summary Care Records?contain important information about any medicines you are taking, allergies you suffer from and any bad reactions to medicines that you have had.Giving healthcare staff access to this information can prevent mistakes being made when caring for you in an emergency or when your GP practice is closed.You can choose whether or not to have a Summary Care Record.Who can see my Summary Care Record?Only healthcare staff involved in supporting or providing your care can see your Summary Care Record. These:need to be directly involved in caring for you; need to have an NHS Smartcard with a chip and passcode (like a bank card and PIN); will only see the information they need to do their job; and should have their details recorded. Healthcare staff will ask your permission every time they need to look at your Summary Care Record. If they cannot ask you, for example if you are unconscious, they may look at your Summary Care Record without asking you. If they do this, they will make a note on your record to say why they have done so.What are my choices with Summary Care Records?You can choose to have a Summary Care Record. You do not need to do anything. This will happen automatically. You can choose not to have a Summary Care Record. If you do not want a Summary Care Record, you need to complete the opt-out form below. Please consider carefully before completing this form and opting out as this record may help with your care when you attend hospital or are treated by someone other than the practice.OPT OUT FORM FOR SUMMARY CARE RECORDTitle:Surname:Forenames:Address:Date of birth:NHS Number if known:Signature: ................
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