When We Are Closed - Home | MSW



MANDALAY933 Blackburn Road, Sharples, Bolton, BL1 7LR-5715013843000TelephoneTelephone 01204 309206 Dr. E. Acomb Dr. C. P. Mercer Dr. J. R. Jones Fax 01204 597949 Dr. J. Y. Bax MEDICAL CENTRE New Patient QuestionnaireIn a bid to help prevent and detect fraud, Mandalay Medical Centre will be implementing a new registration system.We will now require identification before we are able to register you at the practice.Adults (over 18 ) will be required to provide two forms of identification of a current photo ID and a current proof of address.We accept the following;PassportDriving LicenceBirth CertificateMarriage CertificateLocal Authority Rent CardPaid Utility BillsBank/Building Society StatementsNational Insurance Number CardsPapers from the Home OfficeP45Children (under 18) will require one form of identification.We accept the following;Birth CertificatePassportWe will take a photocopy of your identification and it will be included in your patient records held at Mandalay Medical Centre.Unfortunately if your identification is not provided along with your purple registration form and a completed questionnaire, you will not be registered at the practice until these are complete.Practice Details Our address933 Blackburn Road, Sharples, Bolton, BL1 7LRTelephone 01204 309206 Fax 01204 597949 Website mandalaymedicalcentre.nhs.uk Opening Hours:Monday08:00 - 20:00Tuesday08:00 - 18:30Wednesday08:00 - 20:00Thursday08:00 - 18:30Friday07.30 - 18:30WeekendclosedWhen We Are ClosedIf you require urgent medical attention or advice outside of normal surgery hours please call 01204 463999Out-of-hours services are generally busy so please think carefully before asking to see a doctor and only do so if you genuinely cannot wait until the surgery re-opens.In a genuine emergency you should call 999. In the event of an emergency such as loss of consciousness, difficulty breathing, unstoppable bleeding or immediate life-threatening emergencies, always dial 999 for an ambulance.Repeat PrescriptionsNew patients will need to be seen by the doctor before any medication can be issuedRepeat prescriptions are issued for medication which your doctor has agreed you need to take on a regular basis. These are issued on a two monthly basis, but you will need to see your doctor periodically so that your treatment can be monitored.All prescriptions requests take 48 working hours to process when ordered before 13.00 if ordered after this time they will be processed the next day.You may request medication using any of the following methodsUse the order form attached to your prescription, tick the items you require and hand it in at reception. If you do not have your order form you may write down the items you need including the name of the drug, the strength how often you take them and how many you have with your name D.O.B and contact number.Use the order form attached to your prescription, tick the items you require and send it through the post enclosing a SAE if you require your prescription posting back to you, or you may collect it yourself at the surgery, or arrange for someone else to collect it for you.Using our online services please complete the form inside this pack, you should receive an email from the practice within 3-4 working days with the new account details ( please note you will need to see the GP for your first prescription as a new patient)By fax to 01204 597 949. Write down the items you need, including the name of the drug, the strength, how often you take them and how many you have. With your name D.O.B and contact number.If you are housebound we will accept a prescription request over the phone.CollectionsPlease give 48 hours notice (this is from the day that we process your request and does not include weekends)Prescriptions may be picked up during the hours we are open.You can ask your pharmacy to collect your prescriptions and deliver them for you. Please contact the pharmacy of your choice if you wish to use this service (not all pharmacy’s offer this service) If you would like to nominate a pharmacy/appliance contractor to electronically receive your prescriptions please complete the nomination form enclosed in this pack.Please note: previous nominated pharmacies/appliance contractors will be automatically removed upon registering at the practice unless a new nomination form is completed.Please take the time to read this with regards to your new registration.From January 2015, not only are we accepting patients who live within our practice area but we are now accepting patients who live outside the practice area and outside of Bolton. Please speak to a Receptionist with regards to what areas fall outside the practice area.If you fall into this category, for example you live in Heaton or perhaps outside of Bolton i.e. Bury, you are more than welcome to continue with your registration but we do have to inform you that you will not receive Home Visits from the surgery, should you ever need one.If you are happy to proceed with the registration with the knowledge that you will not receive a Home Visit, please would you sign the Declaration form overleaf and return with you registration form and questionnaire.Once you are registered we can send you a copy of your declaration form through the post, for your records.Any problems then please do ask at Reception, were will be happy to help with your query.PATIENT INFORMATION & DECLARATION FORMWe have recently registered you at the practice as an ‘out of area’ registered patient. We are aware that you live outside the practice area (catchment area) and when we registered you we explained that we are not required to provide you with a home visit. You may on occasion, develop an urgent illness or injury at home that means attending the GP surgery as normal would not be appropriate. If you require urgent medical services please contact the practice in the first instance. If we determine you need access to services local to where you live we may ask you to call NHS 111. If urgent care services are required NHS 111 will direct you to a service that has been established by NHS England for patients such as you. This local service could be a GP practice near to where you live, the local walk-in or urgent care centre. In these circumstances you will need to provide our practice details to the urgent care provider to allow them to transfer your consultation data to us so we can update your records.REGISTRATION DECLARATIONYou are accepted on to our list under this arrangement because it was agreed it was clinically appropriate and practical to register you in this way today.In the event that your health requirements change and it is that our professional opinion would be that it would be more clinically appropriate and practical for you to register with a GP practice nearer to your home to provide home visits or urgent appointments more conveniently, then the terms of this registration will change and you will be advised to register with a GP practice closer to home.PATIENT DECLARATIONPRACTICE DECLARATION I understand the terms and urgent care arrangements of this registration:Name: Date:Information provided by:Name:Date:About Patient Online ServicesRequest your repeat prescriptions onlineBook appointments with a GP (This service is only available to patients over the age of 16 years)Access your medical records online (This service is only available to patients over the age of 16 years)Request your repeat prescriptions quickly online by logging into your account and simply ticking the appropriate boxes. You can review the progress of your repeat prescriptions and any message that the practice may have sent to you.Accessing my medical records online.Have the ability to see you current medications, any allergies you may have and any adverse reaction you may have suffered. Please complete the form overleaf and provide the surgery with photograph identification.Application for Online Access.Surname:First Name:Date of Birth:Address including Postcode:????Email Address:Telephone Number:Mobile Number:?I wish to have access to the following online services ( please tick all that apply):?1. Booking Appointments:2. Requesting repeat prescriptions:3.Accessing my medical record:?I wish to access my medical record and understand and agree with each statement (tick)?1. I have read and understood the information leaflet provided by the practice:2. I will be responsible for the security of the information that I see or download:3. If I choose to share my information with anyone else, this is at my own risk:4. I will contact the practice as soon as possible if I suspect that my account has been accessed by someone without my agreement:5. If I see information in my record that is not about me or is inaccurate, I will contact the practice as soon as possible:??Signature:Date:New Patient QuestionnaireFor patients that are under 18 please fill in appropriate sections. We have marked these with *Personal Details Name * D.O.B. * Title: Gender: *Address *Contact details or contact details if parent or carerLandline: *Mobile: *Email:Preferred method of contact: please indicateHome tel Mobile Email Post NHS number:Occupation:Marital Status:(please circle one option)Single Married Co-habiting Divorced Separated Widowed Next of Kin: *Relationship:Address: if different to aboveMedical history:Personal medical history:Have you suffered/do you suffer from (please circle):Please specify any major illness or operations, with dates38989020955000AnginaAsthma/bronchitis/other chest problemCancerChronic Kidney DiseaseDiabetesEczema/hayfeverEpilepsyHeart Disease/had heart attackHigh blood pressureHigh cholesterolOsteoporosisStrokeMental Health problems: including depression, anxiety, bi-polar, schizophrenia, psychosisSight problems: including glaucomaThyroid problemsOther: please specify*Family medical history:Have any of your parents, brothers or sisters suffered from(please circle)::Please specify whoAnginaAsthma/bronchitis/other chest problemCancerChronic Kidney DiseaseDiabetesEczema/hayfeverEpilepsyHeart Disease/had heart attackHigh blood pressureHigh cholesterolOsteoporosisStrokeMental Health problems: including depression, anxiety, bi-polar, schizophrenia, psychosisSight problems: including glaucomaThyroid problemsOther: please specifyKnown allergies:To whatDetails of the reaction*Repeat medication:Name of drugFrequency (how often taking it)Reason for using drug3403604318000*Do you smoke?7010402667025654029845Yes NoWould you like access to service to get help?7010402667025654029845Yes NoDo you drink alcohol?7010402667025654029845Yes NoWould you like access to service to get help?7010402667025654029845Yes NoDo you use any drugs not prescribed by a doctor?7010402667025654029845Yes NoWould you like access to service to get help?7010402667025654029845Yes NoAre you currently under hospital care?Hospital NameName of ConsultantNature of problemDo you consider yourself to have a disability?Details of impairment: * 80264028575125920529845Physical Yes No12573002476573660016510Sensory Yes No234442017145191452517145Learning disability /difficulty Yes No1562100635011023608890Mental Health Yes NoOther: Women onlyAre you pregnant or had a baby in the last 12 months?7010402667025654029845Yes NoAre you using any form of contraception7010402667025654029845Yes NoIf so, whatHave you ever had a smear test?7010402667025654029845Yes NoDate of last smearHave you ever had a mammogram?7010402667025654029845Yes NoDate of last mammogramHave you ever had any form of surgery/cutting to your genital area?7010402667025654029845Yes NoOther specific issuesAre you a veteran who has any condition related to their service?7010402667025654029845Yes NoAre you a carer for anyone else?22479034290No662940199390Yes – within same household662940169545Yes – within another householdRelationship: They are my5676905080Parent56769029210Child56769041275Relative 56769061595FriendDo you, or anyone else within your household currently have a Social Worker7010402667025654029845Yes NoName of Social Worker:Telephone contact:Are you a young person who is either Looked After or a Care Leaver?2565402984570104026670Yes NoName of Social/Leaving Care Worker:Telephone contact:Ethnic BackgroundWhat is your country of birth?How would you describe your ethnicity?White: British Irish OtherAsian: Asian British Bangladeshi Pakistani Other AsianBlack: Black British African Caribbean Other blackWhat is your preferred spoken language?Do you require an interpreter?7010402667025654029845Yes NoDo you require an interpreter for British Sign Language?7010402667025654029845Yes NoIf under the age of 5 Please complete as much as possible by entering dates below, or bring in a copy of the child record (red book).ImmunisationsDTaP / Polio / HibPCVMen CMMRDTaP IPV1st2ndN/A3rdN/AN/ABoosterN/AN/AN/AN/AIs there any other information that you feel is important for us to know, to ensure we can look after you properly? ……………………………………………………………………………………………………………………………………………………………Name…………………………………. DOB……………… Todays Date…………………Contact Details: Home Number:…………………….. Mobile:………………………. Email:………………………………………………………………………This is one unit of alcohol……and each of these is more than one unitAUDIT – C ( If you score 5 or more on the Audit C, please complete the following questionnaire)Questions - Please score on the right hand sideScoring systemYour score01234How often do you have a drink containing alcohol?NeverMonthlyor less2 - 4 times per month2 - 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+How often have you had 6 or more units if female, or 8 or more if male, on a single occasion in the last year?NeverLess than monthlyMonthlyWeeklyDaily or almost dailyTotal:Please circle your answer to the following questionsSmoking StatusNeverExSmokerAre you a Carer?YesNoEthnicityWhite BritishIrishGypsyOther White BackgroundAfricanCaribbeanMixed / Multiple EthnicityWhite/Black AfricanWhite/BlackCaribbeanWhite/AsianChineseIndianPakistaniBangladeshiArabOther Asian BackgroundAny Other Ethnic GroupAUDIT CScoring systemYour score01234How often do you have a drink containing alcohol?NeverMonthlyor less2 - 4 times per month2 - 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+How often have you had 6 or more units if female, or 8 or more if male, on a single occasion in the last year?NeverLess than monthlyMonthlyWeeklyDaily or almost dailyHow often during the last year have you found that you were not able to stop drinking once you had started?NeverLess than monthlyMonthlyWeeklyDaily or almost dailyHow often during the last year have you failed to do what was normally expected from you because of your drinking?NeverLess than monthlyMonthlyWeeklyDaily or almost dailyHow often during the last year have you needed an alcoholic drink in the morning to get yourself going after a heavy drinking session?NeverLess than monthlyMonthlyWeeklyDaily or almost dailyHow often during the last year have you had a feeling of guilt or remorse after drinking?NeverLess than monthlyMonthlyWeeklyDaily or almost dailyHow often during the last year have you been unable to remember what happened the night before because you had been drinking?NeverLess than monthlyMonthlyWeeklyDaily or almost dailyHave you or somebody else been injured as a result of your drinking?NoYes, but not in the last yearYes, during the last yearHas a relative or friend, doctor or other health worker been concerned about your drinking or suggested that you cut down?NoYes, but not in the last yearYes, during the last year4686300150495Total score00Total score1376045-638175001201420324231100925512322929300Request for my personal confidential information to be withheld from sharing with the Health and Social Care Information Centre (HSCIC)You have 2 options to choose from regarding your Personal Confidential Data (PCD) leaving your GP Practice – Please tick either option 1 or option 2 below. 1.I object to my PCD leaving the practice and being sent to the HSCIC. 2. I will allow my PCD to leave the GP Practice and go to the HSCIC to be used ONLY for HSCIC use, but object to my data being passed on to any other organisation Please fill out the form below and return it to (insert name of practice) Section A: Please complete in BLOCK CAPITALSTitle …………………… Surname / Family Name …………………………………………….Forename(s)…………………………………………………………………………………………..Address………………………………………………………………………………………………..Postcode……………. NHS No (if known)……………… Signature …………………………..---------------------------------------------------------------------------------------------------------------------------Section B: If you are completing this form on behalf of another person or a child your GP practice will consider this request. Please ensure you complete their details in Section A above and your details in Section B below.Your Name …………………………………………. . Your Signature …………………………..Relationship to patient………………………………. Date………………………………………. ----------------------------------------------------------------------------------------------------------------------------Please Note: If you wish to change your decision in the future please inform your GP in writing.Please return to: (insert name and address of practice) -------------------------------------------------------------------------------------------------------------------------- FOR PRACTICE USE ONLY V2CTV3Description19Nu0.XaZ89Dissent from secondary use of GP patient identifiable data29Nu4.XaaVLDissent from disclosure of personal confidential data by Health & Social Care CentreActioned by Practice: Yes / No. Initials………… Date………….. S ................
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