Yiewsley Family Practice - New Patient Registration

 

1. Have you ever registered with this practice before? *

 

2. Title *

 

3.
Name *

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4. Date of Birth *

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5. NHS Number (if known):

 

6. Gender *

 

7. Personal Status *

 

8. Town and Country of Birth: *

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9. Ethnic origin

Please tell us your Ethnic Group *

 

10. Home Adrress *

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11. Contact details *

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12. May we contact you using email? *

 

13. May we contact you using SMS text? *

 

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

Name and address of previous GP

 

Your previous address in the UK *

 

15. If you are from abroad

 

16. If you are returning from the Armed Forces.

 
NHS ORGAN DONATION REGISTRATION

CLICK HERE  If you are interested in becoming an organ donor 

 
NHS BLOOD DONATION REGISTRATION

CLICK HERE  If you are interested in registering as a blood donor


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17. EMERGENCY CONTACT *

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Employment Status *

 

18. Occupation *

 

19. If you have children of your own aged 16 years or under, please list their names and dates of birth below?

 

20. FEMALE PATIENTS ONLY , WOMEN OVER 25

 

21. IMMUNISATIONS

 

22. Are you registered disabled? (If yes, please give details)

 

23. Please tick if you have, or have had, any of the following ILLNESSES:

 

24. SIGNIFICANT MEDICAL CONDITIONS

Please list any serious illnesses / operations / accidents / disabilities with Dates

 

25. CURRENT MEDICATION

Please list any CURRENT MEDICATION, including inhalers and contraception. Please specify dose

 

26. DRUG ALLERGIES

Are you allergic to any medicines? *

 

27. FAMILY HISTORY - Does anyone in your family suffer or have suffered from any of the following *

 

28. Nationality & Language *

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29. CARERS (tick a box if it applies)

 

30. LIFESTYLE *

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31. SMOKING *

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32. ALCOHOL (1 unit of drink = 1/2 pint of beer or 1 glass of wine or 1 single spirits)

How often do you have a drink containing alcohol? *

 

33. How many standard drinks containing alcohol do you have on a typical day? *

 

34. How often do you have six or more drinks on one occasion? *

 

35. ONLINE ACCESS to your medical records (please tick what you would like to do online)

 

36. ONLINE ACCESS AGREEMENT

I wish to access my medical record online and understand and agree with each statement (tick) *

 

37. NHS SUMMARY CARE RECORD

There are strict laws and regulations to ensure that your health records are kept confidential and can only be accessed by health professionals directly involved in your care. There is some sharing of information as detailed below. You can opt out of any of these at any time if you wish.

NHS Summary Care Record (SCR) - this is an electronic record which contains information about the medicines you take, allergies you suffer from and any bad reactions to medicines you have had. Having this information stored in one place makes it easier for healthcare staff to treat you in an emergency, or when your GP practice is closed.Further information is available at www.nhscarerecords.nhs.uk or call 0845 603 8510

I would like to: *

 

38. SHARING YOUR MEDICAL INFORMATION WITH OTHER SERVICES

We may need to share your medical information with other organisations involved in the delivery of your care e.g. Podiatry or District Nursing. We will not share identifiable information with anyone that is not involved in your care unless legally required to.

Are you happy for us to Share Out your full medical records electronically with other services involved in your care and/or to view (Share In) medical records held by other services? *

 

39. PATIENT DECLARATION

Anybody in England can register with a GP practice and receive free medical care from that practice.

The NHS is the UK’s state health service which provides treatment for UK residents. Some services are free, other have to be paid for. A person who is regarded as ordinarily resident in the UK is eligible for free treatment by a GP. A person is ‘ordinarily resident’ for this purpose if lawfully living in the UK for a settled purpose as part of the regular order of his or her life for the time being. Anyone coming to live in this country would qualify as ordinarily resident. Overseas visitors to the UK are not regarded as ordinarily resident if they do not meet this description. If you are not a ‘ordinarily resident’ in the UK you may have to pay for NHS treatment outside of the 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. *

 

40. Patient Signature (Type Name) *

 

41. Date

   DD/MM/YYYY 
 
 
The data supplied by you is processed by SmartSurvey in line with the laws on data protection and confidentiality. SmartSurvey is ISO27001 certified and registered under the Data Protection Act. SmartSurvey processes your information so that it can be sent to your medical practice to enable your registration at the practice as a patient to receive general medical services. SmartSurvey has no other interest in your data other than the above use. It will not share this data with any other party. The data is processed using a secure server based in the UK and forwarded using encrypted communication to the medical practice. There is no profiling or automatic decision making in this process.It is your choice to provide your information to SmartSurvey If you choose not to do so you will need to attend the medical practice in person to register with them.The information you are submitting will be sent encrypted to the medical practice over the Internet, which still isn't 100% secure. If you are worried about this you can instead obtain a form from the medical practice that can be filled in and delivered by hand. You may contact the practice at enquiries.yfp@nhs.net