New Adult Patient Online Registration Please note: Submission of this form does not confirm registration. Personal Details Title ---MrMrsMissMsDr Gender ---MaleFemale Given Name Family Name Previous Surnames (If any) Middle Name(s) Known as/Preferred name Date of birth (dd/mm/yyyy) NHS Number Marital Status ---SingleMarriedDivorcedSeperatedWidowedOtherI do not wish to disclose Town and city of Birth What is your Ethnicity ---White - BritishWhite - IrishWhite - any other White backgroundMixed - White and Black CaribbeanMixed - White and Black AfricanMixed - White and AsianMixed - any other mixed backgroundAsian - IndianAsian - PakistaniAsian - BangladeshiAsian - any other Asian BackgroundBlack - CaribbeanBlack - AfricanBlack - any other Black backgroundOther - ChineseOther - Any other ethnic groupNot stated What is your first language? Do you require a translator? YESNO What is your occupation? Your current Address House Name/Flat Number Street/Road name Town/City Post Code Your Contact Details Home Phone Mobile Phone Work Phone Email Preferred communication method ---No preferenceHome telephone numberWork telephone numberMobile telephone numberEmail addressLetter to home address About you Height(centimetres) Weight(kilograms) What is your current smoking status? ---I have never smokedI am an ex-smokerI currently smoke If you currently smoke, how many per day? Would you like an HIV Test? YESNO Next Medical Records Your previous address in the UK Name of previous GP in the UK Address of you previous GP NHS Organ Donor Donation YESNOI want to register my details on the NHS Organ Donor Register as someone whose organs may be used for transplantation after my death. NHS Blood Donor Registration YESNOI would like to join the NHS Blood Donor register as someone who may be contacted and would be prepared to donate blood. If you are 16+ and speak English fluently, you have the option to register for Patient Access allowing you to book and cancel routine GP appointments online, view blood test results and view your consultations and immunisation history online. If you do not speak English and require an interpreter for appointments, you will be unable to make appointments online. Please contact us to book appointments. If you do not wish to be signed up to Patient Access, please specify below: I want to join Patient AccessI do not want to join patient access Please note that only non-urgent routine 10 minute GP appointments and telephone consultations can be arranged via Patient Access. If you are from abroad Your first UK address where registered with a Doctor If previously resident in the UK, date of leaving Date you first came to live in the UK IF YOU HAVE NOT HAD A GP IN THE UK BEFORE THIS INFORMATION IS REQUIRED TO COMPLETE YOUR REGISTRATION* Next of Kin Next of kin title ---MrMrsMissMsDr Next of kin first name Next of kin last name What is this person's relationship to you? Next of Kin Telephone Number (must be a British contact number) Is your next of kin registered/or will be registering at Thurleigh Road Practice? YESNO Were you ever registered with Armed Forces GP Please indicate if you have served in the UK Armed Forces and/or been registered with a Ministry of Defence GP in the UK or overseas: RegularReservistVeteranFamily Member (Spouse, Civil Partner, Service Child) Address before enlisting Post Code Service or Personnel number Enlistment date Discharge date (if applicable) Footnote: These options 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 charities services BackNext Medical History Diabetes YesNo Date of Diabetes Diagnosis High Blood Pressure YesNo Date of High Blood Pressure diagnosis Heart Attack YesNo Date of Heart Attack diagnosis Asthma YesNo Date of Asthma diagnosis Stroke YesNo Date of Stroke diagnosis Cancer YesNo Date of Cancer diagnosis Type of Cancer? (e.g. bowel cancer, breast cancer etc) Mental Illness YesNo Date of Mental Illness diagnosis Disability YesNo Type of Disability Other Are you a housebound patient? (This means someone who is unable to leave their home environment due to a physical or psychological illness) BackNext Medications Please provide details of any medications you are currently being prescribed (or leave blank if you you are not on any medication) Current/Regular Medication Name: Medication Reason: Eg: Asthma, Diabetes etc Current/Regular Medication Name: Medication Reason: Eg: Asthma, Diabetes etc Current/Regular Medication Name: Medication Reason: Eg: Asthma, Diabetes etc Add any additional current/regular medications here: In an effort to support the NHS Paper Switch-Off Programme (PSO) we will no longer be printing prescriptions. Please ensure that you select a pharmacy below to have any future prescriptions sent through to electronically. Where a pharmacy is not selected, Phillips Pharmacy (70A Clarence Avenue, London SW4 8JP) will automatically be set as a patient's selected pharmacy.* Address Line 1: Address Line 2: City: Post Code: Allergies Please provide details of any allergies that you have (or leave blank if you have no allergies) Name of Allergy: What happens? What is the reaction? Name of Allergy: What happens? What is the reaction? Add any additional allergies here: BackNext Family History Please enter details here if there is any relevant medical history in your family (or leave blank if there is none) High Blood Pressure ---MotherFatherSisterBrotherAuntUncleMaternal GrandmotherMaternal GrandfatherPaternal GrandmotherPaternal GrandfatherGrandmotherGrandfather Diabetes ---MotherFatherSisterBrotherAuntUncleMaternal GrandmotherMaternal GrandfatherPaternal GrandmotherPaternal GrandfatherGrandmotherGrandfather Mental Illness ---MotherFatherSisterBrotherAuntUncleMaternal GrandmotherMaternal GrandfatherPaternal GrandmotherPaternal GrandfatherGrandmotherGrandfather Stroke ---MotherFatherSisterBrotherAuntUncleMaternal GrandmotherMaternal GrandfatherPaternal GrandmotherPaternal GrandfatherGrandmotherGrandfather Cancer ---MotherFatherSisterBrotherAuntUncleMaternal GrandmotherMaternal GrandfatherPaternal GrandmotherPaternal GrandfatherGrandmotherGrandfather Heart Attack ---MotherFatherSisterBrotherAuntUncleMaternal GrandmotherMaternal GrandfatherPaternal GrandmotherPaternal GrandfatherGrandmotherGrandfather Asthma ---MotherFatherSisterBrotherAuntUncleMaternal GrandmotherMaternal GrandfatherPaternal GrandmotherPaternal GrandfatherGrandmotherGrandfather BackNext Carers Please provide details if you are a Carer, are Cared for, or are on an disability register (continue to the next question if not) Are you A CARER FOR a friend or a relative? NoYes Are you CARED FOR by a friend or a relative? NoYes BackNext Summary Care Record The Summary Care Record (SCR) is an electronic record of important patient information, created from GP medical records. It can be seen and used by authorised staff in other areas of the health and care system involved in your direct care. Access to SCR information means that care in other settings is safer, reducing the risk of prescribing errors. It also helps avoid delays to urgent care. As standard, the SCR holds: Your name, address, date of birth and NHS number Your current medication Your allergies and details of any previous bad reactions to medicines You can also choose to share an enhanced record. This is particularly useful if you are elderly, or have complex or long term conditions. The enhanced SCR holds: Significant medical history (past and present) Reason for medications Anticipatory care information (such as information about the management of long term conditions) End of life care information Immunisations Summary Care Record Consent* I consent to share standard information via the Summary Care Record.I do not consent to share any information via the Summary Care Record.I consent to share enhanced information via the Summary Care Record BackNext Alcohol Using the scoring system above, please score yourself between 0-4 for the following questions. If you do not drink, please enter 0 in all the boxes. 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? How often during the last year have you been unable to remember what happened the night before because you had been drinking? Has a relative or friend, doctor or other health worker been concerned about your drinking or suggested that you cut down? YesNo BackNext Identification Please upload a copy of your driving licence, passport or ID card so as we can verify your identity. (File types accepted .png, .jpg and .pdf. Maximum file size 5mb) We also need to see 1 document as proof of address. Please upload either a utility/telephone bill/signed and dated tenancy agreement/mortgage agreement/council tax bill/bank or credit card statement/driver’s licence if not used as proof of ID. Please ensure that any documentation sent for proof of address is not more than 3 months old: (File types accepted .png, .jpg and .pdf. Maximum file size 5mb) 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 a) I understand that I may need to pay for NHS treatment outside of the GP practiceb) 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 requestedc) 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. Signature Who is signing* Signature of PatientSignature on behalf of patient Please sign in the box below using your mouse or on the screen of your tablet. Print name of signatory: By clicking submit you confirm that you have read and agreed our terms of service and privacy policy Agree Complete this section if you live in another 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. NON-UK EUROPEAN HEALTH INSURANCE CARD (EHIC), PROVISIONAL REPLACEMENT CERTIFICATE (PRC) DETAILS and S1 FORMS Do you have a non-UK EHIC or PRC? YESNO If YES, Please enter details from your EHCI or PRC below: Country code: Name: Given Names: Date of birth Personal Identification Number: Identification Number of the Institution: Identification Number of the Card: Expiry date: PRC Validity period - a) From: PRC Validity period - a) To: Please tick if you have an S1 (eg. 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. YESNO 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. 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