Family doctor services registration

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1 GMS1-JUL12_GMS 1 17/07/ :15 Page 1 Family doctor services registration GMS1 Patient s details n Mr n Mrs n Miss n Ms Date of birth Surname First names Please complete in BLOCK CAPITALS and tick n as appropriate 4 NHS No. n Male n Female Home address Previous surname/s Town and country of birth Postcode Telephone number Please help us trace your previous medical records by providing the following information Your previous address in UK Name of previous doctor while at that address Address of previous 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 or Personnel number Enlistment date If you are registering a child under 5 n I wish the child above to be registered with the doctor named overleaf for Child Health Surveillance If you need your doctor to dispense medicines and appliances* n I live more than 1 mile in a straight line from the nearest chemist n I would have serious difficulty in getting them from a chemist *Not all doctors are authorised to dispense medicines n Signature of Patient n Signature on behalf of patient Date / / Version 01/02 Please see overleaf re: Organ donation

2 GMS1-JUL12_GMS 1 17/07/ :15 Page 2 Family doctor services registration GMS1 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. Please tick the boxes that apply. Any of my organs and tissue or Kidneys Heart Liver Corneas Lungs Pancreas Any part of my body Signature confirming my agreement to organ/tissue donation Date / / For more information, please ask at reception for an information leaflet or visit the website or call NHS Blood Donor registration 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 / / For more information, please ask for the leaflet on joining the NHS Blood Donor Register My preferred address for donation is: (only if different from above, e.g. your place of work) Postcode: To be completed by the doctor Doctors Name HA Code I have accepted this patient for general medical services For the provision of contraceptive services I have accepted this patient for general medical services on behalf of the doctor named below who is a member of this practice Doctors Name, if different from above HA Code I am on the HA CHS list and will provide Child Health Surveillance to this patient or I have accepted this patient on behalf of the doctor named below, who is a member of this practice and is on the HA CHS list and will provide Child Health Surveillance to this patient. Doctors Name, if different from above HA Code I will dispense medicines/appliances to this patient subject to Health Authority s Approval I am claiming rural practice payment for this patient. Distance in miles between my patient s home address and my main surgery is I declare to the best of my belief this information is correct and I claim the appropriate payment as set out in the Statement of Fees and Allowances. An audit trail is available at the practice for inspection by the HA s authorised officers and auditors appointed by the Audit Commission. Practice Stamp Authorised Signature Name Date / / HA use only Patient registered for GMS CHS Dispensing Rural Practice

3 Minchinhampton Surgery NEW PATIENTS ON REPEAT MEDICATION If you are on repeat medication please ensure you book a review with one of the doctors before your medication is due to run out. Otherwise there can be a delay in organising a repeat Prescription. Please bring photographic ID (passport, driving licence) with you when handing in your completed registration pack

4 The Surgery, Bell Lane, Minchinhampton. Glos. GL6 9JF. Tel: Fax: Dr Susie Weir Dr David Pouncey Dr Andy Simpson Dr Anne Cain Dr Hein le Roux Dr Pippa Xerri Welcome to Minchinhampton Surgery. It may take some time for your records to arrive from your previous doctor. In the meantime, please could you complete this form. If you are a carer and you would like this to be known to your doctor, please ask reception to give you a carer s form to complete. If you would like a new patient health check, please book a 20 minute appointment with a Practice nurse. If you are already on regular medication please book this 20 minute health check with one of the doctors. This information will be recorded on your medical record on the Practice s computer system. Whether it is on paper or computer, everyone in the NHS has a legal duty to keep information about you confidential. Date form completed: Surname: First name(s): Signature: Date of birth: Have you ever been registered with this Practice before, if so under what name? Ethnic Origin (please tick the appropriate box) White Black Caribbean Black African Black other Indian Pakistani Bangladeshi Chinese Other Asian Other ethnic group, Other ethnic, mixed origin Prefer not to specify First Language: Address: : Post code: : Home phone: Mobile: (We send appointment reminders by text message) address:. Occupation: School (18 and under only): : :... Next of Kin:.... : Tel No Emergency contact name: Emergency contact tel: Are you an Armed Forces Veteran YES/NO If you are, please state Service No: Have you previously been set up for Electronic Prescribing? (this is when prescriptions you have ordered are sent to the pharmacy electronically) YES/NO Which Pharmacy:.. (If this is outside the local area we assume you will want this removed) Do you want to be set up for Electronic Prescribing to a local Pharmacy? YES/NO Which Pharmacy:. SMOKING: (please tick the appropriate box) Never smoked Ex-smoker Smoker Quantity IF YOU ANSWER YES, TO ANY OF THE FOLLOWING QUESTIONS PLEASE GIVE DETAILS. Have you ever had any serious illnesses or been in hospital? Do you have any current or long-term problems? Are you currently taking any medication? Do you have any allergies?.do you have any family history of serious illness eg. heart disease, cancer, asthma or diabetes?.

5 YOUR NAME: DATE OF BIRTH: Minchinhampton Surgery offers its patients the choice of having a Summary Care Record. The new NHS Summary Care Record has been introduced to help deliver better and safer care and give you more choice about who you share your healthcare information with. What is the NHS Summary Care Record? The Summary Care Record contains basic information about: any allergies you may have, unexpected reactions to medications, and any prescriptions you have received. The intention is to help clinicians in A & E Departments and Out of Hours health services to give you safe, timely and effective treatment. Clinicians will only be allowed to access your record if they are authorised to do so and, even then, only if you give your express permission. You will be asked if healthcare staff can look at your Summary Care Record every time they need to, unless it is an emergency, for instance if you are unconscious. Children under the age of 16 Patients under 16 years will not receive this form, but will have a Summary Care Record created for them unless we are advised otherwise. If you are the parent or guardian of a child then please either make this information available to them or decide and act on their behalf. Ask the surgery for additional forms if you want to opt them out. You do not have to have a Summary Care Record, although you are strongly recommended to consider this choice. Please tick the appropriate box: YES I would like a Summary Care Record NO I do not want a Summary Care Record Signed Date HealthSpace information In addition, patients over 16 can register on a secure website called HealthSpace for a Basic account which gives you access to a Personal Health Organiser. Register at to do this. If you go a stage further you can register for an Advanced account which will entitle you to see a copy of your Summary Care Record once it has been created. Complete the Advanced Registration application and print off the form and contact your Patients Advice and Liaison Service (PALS) office to find out where you should go to register for an Advanced HealthSpace Account. You can do this by ing or by telephoning the PALS on Advisers are available Monday to Friday from 9.00am to 5.00pm. When you register you must remember to bring along with you 3 items of identification, Passport and/or Driving Licence and 2 Utility Bills current within the last 3 months. For more information visit either or or call

6 GLOUCESTERSHIRE HEALTH AUTHORITY ORGAN/BLOOD DONOR REGISTRATION FORM Surname:... Forename(s):. Address:... Postcode:.. NHS No.: Date of Birth: D D M M Y Y Registered General Practitioner: Date completed:. Please tick as appropriate Please register me on the NHS Organ Donor Register as someone whose organs can be used for transplantation purposes after my death. Either Any parts of my body Or my Kidneys Heart Liver Corneas Lungs Pancreas May be used in the treatment of others I would like to join the NHS Blood Donor Register as someone who may be contacted and would be prepared to donate blood. I have given blood in the last 3 years.

7 YOUR NAME: DATE OF BIRTH:! "!" #$ % " &'& # +!, +!-+.*/01, ( ) * $%&

8 Minchinhampton Surgery Patient Online: Access to GP online services Registration form Surname First name Date of birth Address Postcode address Telephone number Mobile number I wish to have access to the following online services (tick all that apply): Booking appointments Requesting repeat prescriptions Accessing my medical record including test results (this only includes records from date access approved) Application for online access to my medical record I wish to access my medical record online and understand and agree with each statement (please tick) I have read and understood the information leaflet provided by the practice I will be responsible for the security of the information that I see or download If I choose to share my information with anyone else, this is at my own risk I will contact the practice as soon as possible if I suspect that my account has been accessed by someone without my agreement If I see information in my record that it not about me, or is inaccurate I will log out immediately and contact the practice as soon as possible Signature Date For practice use only Identity verified through (tick all that apply) Vouching Vouching with information in record Photo ID Proof of residence Name of verifier Date Name of person who authorised (if applicable) Date account created Date passphrase collected Date

9 Minchinhampton Surgery Patient Online: Records Access through the surgery website Patient information leaflet It s your choice If you wish to, you can now use the internet to book appointments with a GP, request repeat prescriptions for any medications you take regularly and look at your medical record online. You can also still use the telephone or call in to the surgery for any of these services as well. It s your choice. Being able to see your record online might help you to manage your medical conditions. It also means that you can even access it from anywhere in the world should you require medical treatment on holiday. If you decide not to join or wish to withdraw, this is your choice and practice staff will continue to treat you in the same way as before. In general this decision will not affect the quality of your care. You will be given login details, so you will need to think of a password which is unique to you. This will ensure that only you are able to access your record unless you choose to share your details with a family member or carer. The practice has the right to remove online access to services for anyone that doesn t use them responsibly. GP appointments online Repeat prescriptions online It s your choice It will be your responsibility to keep your login details and password safe and secure. If you know or suspect that your record has been accessed by someone that you have not agreed should see it, then you should change your password immediately. If you can t do this for some reason, we recommend that you contact the practice so that they can remove online access until you are able to reset your password. If you print out any information from your record, it is also your responsibility to keep this secure. If you are at all worried about keeping printed copies safe, we recommend that you do not make copies at all. View your GP records

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