Family doctor services registration
|
|
- Pamela Marsh
- 7 years ago
- Views:
Transcription
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 community.pals@glos.nhs.uk 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
Family doctor services registration
Family doctor services registration GMS1 Patient s details Mr Mrs Miss Ms Date of birth Surname First names Please complete in BLOCK CAPITALS and tick as appropriate NHS No. Male Female Home address Previous
More informationNHS Family doctor services registration GMS1
NHS Family doctor services registration GMS1 Patient s details Please complete in BLOCK CAPITALS and tick as Appropriate Mr Mrs Miss Ms Surname Date of birth d d m m y y First names NHS No. Male Female
More informationAPPLICATION FOR GENERAL MEDICAL SERVICES WITH THE CHARTER MEDICAL CENTRE
Your GP will be: APPLICATION FOR GENERAL MEDICAL SERVICES WITH THE CHARTER MEDICAL CENTRE Dr From AUG 2015 PLEASE COMPLETE THIS FORM IN CAPITAL LETTERS Have you been registered at this practice before?
More informationFamily doctor services registration
Family doctor services registration GMS1 Patient s details Please complete in BLOCK CAPITALS and tick as appropriate Surname Mr Mrs Miss Ms Date of birth First names NHS No. Male Female Home address Previous
More informationDate of birth Gender NHS number (if known) Town/Country of birth. Home Telephone no. Work Telephone no.
ADULT - FEB 15 Office use only Staff initials Date ID seen Welcome to Wokingham Medical Centre Thank you for completing this registration form. When registering in person at the surgery please supply two
More informationAnd finally please do not forget to SIGN the form at the bottom front.
Shrewsbury School Sanatorium 11 Ashton Road, Shrewsbury, SY3 7AP Medical Officer: Dr Maurice Price MBBS London 1999 DRCOG MRCGP Senior Sister: Judith Lea, ONC, RGN, RM, DiPP, ENP Telephone: 01743 280860
More informationMILLRISE MEDICAL PRACTICE NEW PATIENT REGISTRATION/HEALTH QUESTIONNAIRE
MILLRISE MEDICAL PRACTICE NEW PATIENT REGISTRATION/HEALTH QUESTIONNAIRE PLEASE COMPLETE THIS FORM IN BLOCK CAPITALS. To register with the Practice please complete this questionnaire as fully as possible.
More informationTHE ROWANS SURGERY MEDICAL HISTORY QUESTIONNAIRE MALE & FEMALE 18+
THE ROWANS SURGERY MEDICAL HISTORY QUESTIONNAIRE MALE & FEMALE 18+ Surname: First Name: Date of Birth: NHS Number: / / Mobile Telephone No: Male / Female If you wish to sign up for Vision On-Line services
More informationPlease make an appointment with the nurse for a new patient medical within one month of joining the practice.
New Patients If you are registering with us as a new patient, please be aware we will need to ask you to provide evidence of identification (ID) as part of the registration process. A combination of two
More informationPlease note that you will not be able to see a doctor or a nurse or obtain any of the free National Health services until you have:
Dr F Docrat and Partners Sparkenhoe Street Leicester, LE2 0TA Tel: 0116 295 7835 Fax: 0116 295 7836 www.shefamedicalpractice.co.uk Dear New Patient, Thank you for your application to join. Please note
More informationFortrose Medical Practice
Fortrose Medical Practice GP Partners: Dr Sandy MacGregor, Dr Will Fraser, Dr Iain Forth & Dr Jude Watmough Associate GP: Dr Shona Forth Station Road Fortrose Ross-shire IV10 8SY Phone: Fax: Email: Website:
More informationTenant transfer application
For office use Registration No. Tenant transfer application Main applicant Place passport sized photo of main applicant here Place passport sized photo of joint applicant here If you would like any part
More informationKeele Practice New Patient Information
) )Dip/tetanus/polio )1 Keele Practice New Patient Infmation Name Todays date Male/Female University Address Uni tele: Mobile: Date of Birth Home Address email address: Home tele: Significant Medical Histy
More informationPitcairn Medical Practice New Patient Questionnaire
/ / *Areas are mandatory. Failure to complete may delay the time taken to process your registration *Surname: *Forename(s): *Address: *Date of Birth/CHI: / Marital Status: Sex: Male / Female (delete as
More informationPharmaceutical Needs Assessment (PNA) Consultation Response Form
Pharmaceutical Needs Assessment (PNA) Consultation Response Form Hertfordshire Health and Wellbeing Board is consulting on the draft Hertfordshire PNA and welcome all views and comments. The consultation
More informationClaims Management Claim Form. When you have filled in the form, please send it to us at:
For our use only.../... Claims Management Claim Form When you have filled in the form, please send it to us at: Solicitors Regulation Authority Claims Management The Cube 199 Wharfside Street Birmingham
More informationThe Care Record Guarantee Our Guarantee for NHS Care Records in England
The Care Record Guarantee Our Guarantee for NHS Care Records in England Introduction In the National Health Service in England, we aim to provide you with the highest quality of healthcare. To do this,
More informationLATHOM HOUSE SURGERY. Records Online Access. Online Electronic Medical Record Viewing Patient Information Leaflet
LATHOM HOUSE SURGERY Records Online Access Online Electronic Medical Record Viewing Patient Information Leaflet 1 Introduction : This practice is piloting a project that allows you to view your medical
More informationSubject Access Request Form Data Protection Act 1998 Application for Access to Personal Information. December 2013
Subject Access Request Form Data Protection Act 1998 Application for Access to Personal Information December 2013 CONTACTS Please return this completed form to: Information Governance Digital Services
More informationNot known. 2) If you currently smoke, would you like to be offered a referral to our Stop Smoking team? Yes No
Specialist Wheelchair Services Specialist Wheelchair Service Referral Form Central London Wheelchair Services 306 Kensal Road London W10 5BE Tel: 0208 962 3939 Fax: 020 8962 3965 Email: clcht.wheelchairs@nhs.net
More informationBristol, North Somerset, Somerset and South Gloucestershire Area Team 2014/15 Patient Participation Enhanced Service
Bristol, North Somerset, Somerset and South Gloucestershire Area Team 2014/15 Patient Participation Enhanced Service Practice Name: St George Health Centre Practice Code: L81062 Signed on behalf of practice:
More informationMembership application form
Membership application form Mr / Mrs / Miss / Ms / Other Surname First name(s): Address: Post Code: Tel. Mobile Email address If you have lived at this address for less than three years, please give previous
More informationCAN I GET A BLUE BADGE?
Appendix 1 Application for a Blue Badge Durham County Council Children and Adults Services Blue Badge Team PO Box 115 Green Lane, Spennymoor County Durham, DL16 9BX Tel: 03000 269 425 Email Bluebadgescheme@durham.gov.uk
More informationRekindling House Dual Diagnosis Specialist
Rekindling House Dual Diagnosis Specialist Tel: 01582 456 556 APPLICATION FOR TREATMENT Application Form / Comprehensive Assessment Form Please provide as much detail as you can it will help us process
More informationApplication for Access to GP Medical Records (Access to Health Records Act 1990 / Data Protection Act 1998)
(Preston Office) 3 Caxton Road, Fulwood, Preston, PR2 9ZZ (Access to Health Records Act 1990 / Data Protection Act 1998) Under the Data Protection Act 1998 you are entitled to apply for access to your
More informationAPPLICATION FOR FINANCIAL ASSISTANCE
APPLICATION FOR FINANCIAL ASSISTANCE BEFORE COMPLETING THE APPLICATION FORM, PLEASE CAREFULLY READ THE NOTES BELOW. When you have completed the application form, you should detach these notes and keep
More informationThe CILEx Compensation Fund Claims Application Form
The CILEx Compensation Fund Claims Application Form Please complete this form to make a claim for a loss you have incurred. When you have filled in the form, please send it to us at: The CILEx Compensation
More informationData Protection Act 1998 Subject Access Request - Application Form
Data Protection Act 1998 Subject Access Request - Application Form Subject to certain exemptions, you have a right to information held about you i.e. your personal data. You as the Data Subject have a
More informationTHE VILLAGE SURGERY - Southwater
ADULT NEW PATIENT HEALTH QUESTIONNAIRE To register with the Practice please complete this questionnaire as fully as possible and let us have it back before your new patient health check appointment with
More informationLOCAL PATIENT PARTICIPATION REPORT
LOCAL PATIENT PARTICIPATION REPORT Practice Name: Granville Medical Centre Y code: Y00918/ Redbridge 1 Establish a Patient Reference Group (PRG) comprising only of registered patients The table below reflects
More informationThe Care Record Guarantee Our Guarantee for NHS Care Records in England
The Care Record Guarantee Our Guarantee for NHS Care Records in England January 2011, version 5 Introduction In the National Health Service in England, we aim to provide you with the highest quality of
More informationwww.studenthealth.qmul.ac.uk
Queen Mary University of London Student Health Service Student Health Service Geography Building 327 Mile End Road Queen Mary University of London Mile End Road London E1 4NS Tel: 020 7882 8710 Fax: 020
More informationSection 1 - for you to f ill in
Discovery Account Applicat ion Form You should use this application form when you are applying for the following accounts. Danske Discovery Current Account (for people aged 11 to 17) Danske Discovery Savings
More informationEDf EnErGY trust. APPLiCAtion for financial ASSiStAnCE WHO CAN APPLY FOR A GRANT? HOW CAN THE TRUST HELP?
EDf EnErGY trust APPLiCAtion for financial ASSiStAnCE BEforE CoMPLEtinG the APPLiCAtion form, PLEASE CArEfULLY read the notes BELoW. When you have completed the application form, you should detach these
More informationEstover Surgery New Patient Questionnaire
Date of Completion: Personal Details Title: Mr Mrs Miss Ms Dr Other (please circle) Name: Date of Birth: Mobile Number: Home Telephone Number: Work Telephone Number: Contact Email Address: Marital Status:
More informationBlue Badge Scheme Application Form
Bedford Borough Council Blue Badge Scheme Application Form This form must be completed for new and reapplications. Please tick box as appropriate. You must complete all relevant sections of the application
More informationHousing Application Form
Housing Application Form 1 Red Row Renton Office Use Only: G82 4PL Date received: 01389 721216 Reference Number: 07974 745 462 info@cordalehousing.org.uk www.cordalehousing.org.uk This is a housing application
More informationVacancies. Advice Workers- Edinburgh 2 Full Time (Job share might be considered) (36.25 hours a week/ 20,931 per annum )
Vacancies Advice Workers- Edinburgh 2 Full Time (Job share might be considered) (36.25 hours a week/ 20,931 per annum ) FAIR is an advice and information service for people with learning disabilities and
More informationHolden + Co. Complaint Form
For office use only Complaint Form We are sorry that you feel that the service you have received from Holden and Co has not been as expected and that you wish to complain. Holden + Co Solicitors and Advocates
More informationPlanning Ahead. A guide for patients and their carers
Planning Ahead A guide for patients and their carers Somerset Health Community January 2015 Planning ahead Content Page Introduction 3 Key references and useful websites 4 Section 1 Preferred priorities
More informationSurname: Postcode: I can attend each day of the Summer School and all 16 Saturday sessions. I have completed all information in sections A, B, C and D
CHOICE Study with the world s leading Social Science institution Summer School: Monday 17 Friday 21 August 2015 16 Saturday Sessions: 19 September 2015 5 March 2016 Deadline Friday 20 March 2015 First
More informationStandard Reporting Template
Standard Reporting Template Practice Name: Walderslade Surgery Practice Code: C85008 South Yorkshire and Bassetlaw Area Team 2014/15 Patient Participation Enhanced Service Reporting Template Signed on
More informationMental Health Acute Inpatient Service Users Survey Questionnaire
Mental Health Acute Inpatient Service Users Survey Questionnaire What is the survey about? This survey is about your recent stay in hospital for your mental health. Who should complete the questionnaire?
More informationWork Phone. Mobile / / Policy Number Date Issued Number of Travellers. Date of Booking Departure Date Return Date Total Days
Travel Insurance Claim Form Cancellation You must register any claim within 30 days of completion of your travel. Please supply original documents of the evidence you intend to rely on for your claim,
More informationHow To Share Your Health Records With The National Health Service
HOW WE USE YOUR PERSONAL INFORMATION Information Leaflet Your Health. Our Priority. Page 2 of 9 Introduction This Leaflet explains why the NHS collects information about you and how it is used, your right
More informationCENTRAL AVENUE SURGERY ARDROSSAN HEALTH CENTRE ARDROSSAN KA22 7DX. TEL 01294 463838 Fax 01294 462798 www.ardrossanhealthcentre.co.
CENTRAL AVENUE SURGERY ARDROSSAN HEALTH CENTRE ARDROSSAN KA22 7DX TEL 01294 463838 Fax 01294 462798 www.ardrossanhealthcentre.co.uk EVENINGS, WEEKENDS & PUBLIC HOLIDAYS please telephone 111 for urgent
More informationFULL-TIME APPLICATION FORM
Learner Number: FULL-TIME APPLICATION FORM St Peters Street Lowestoft Suffolk NR32 2NB Telephone: 01502 583521 Fax: 01502 500031 Email: info@lowestoft.ac.uk www.lowestoft.ac.uk 1 st choice course 2 nd
More informationPATIENT INFORMATION BOOKLET (Version: August 2015)
PATIENT INFORMATION BOOKLET (Version: August 2015) 2, St Georges Road, Stoke, Coventry, CV1 2DL Tel: 024 7622 4438 Fax: 024 7622 9782 Email: parkhousesurgery@nhs.net PARK HOUSE SURGERY IS COMPLIANT WITH
More informationPatient complaint form
Patient complaint form 1 This form is for you to make a complaint, in the strictest confidence, about a doctor to the General Medical Council. You do not have to use this form but, if you do, it will help
More information62 BATTLE ROAD ERITH, KENT DA8 1BJ TEL: 01322 432997 Fax: 01322 442324 DR K S NANDRA
62 BATTLE ROAD ERITH, KENT DA8 1BJ TEL: 01322 432997 Fax: 01322 442324 DR K S NANDRA Patient Participation Group Report March 2013 The Bulbanks Medical Centre Patient Participation Group currently has
More informationPRIVATE MEDICAL INSURANCE BUSINESS HEALTHCARE AND CORPORATE HEALTHCARE
MORATORIUM APPLICATION FORM PRIVATE MEDICAL INSURANCE BUSINESS HEALTHCARE AND CORPORATE HEALTHCARE For employees (new business and mid-term joiners) and addition of dependants to apply for VitalityHealth
More informationSUBJECT ACCESS REQUEST DATA PROTECTION ACT 1998
SUBJECT ACCESS REQUEST DATA PROTECTION ACT 1998 To be completed by those requesting information held by the Council about them, or completed by their representative. INSTRUCTIONS The Data Protection Act
More informationPLEASE COMPLETE AND RETURN
PLEASE COMPLETE AND RETURN Voluntary Care Network Application Name of Client (Last) (First) (Middle Initial) Street Address Telephone (home) City State Zip Telephone (alternate) Date of Birth US Citizen
More informationDerbyshire & Nottinghamshire Area Team 2014/15 Patient Participation Enhanced Service REPORT
Derbyshire & Nottinghamshire Area Team 2014/15 Patient Participation Enhanced Service REPORT Practice Name: Oakenhall Medical Practice Practice Code: C84095 Signed on behalf of practice: Lisa Ellison (Practice
More informationPatient Participation Enhanced Service 2014/15 Annex D: Standard Reporting Template
London Region North Central & East Area Team Complete and return to: england.lon-ne-claims@nhs.net no later than 31 March 2015 Practice Name: The North London Health Centre Practice Code: F85642 Signed
More informationAnnex D: Standard Reporting Template
Annex D: Standard Reporting Template Practice Name: Stanley Court Surgery Practice Code: N84611 Lancashire Area Team 2014/15 Patient Participation Enhanced Service Reporting Template Completed by: Lesley
More informationWESTERN ROAD SURGERY PATIENT NEWSLETTER JULY 2008
WESTERN ROAD SURGERY PATIENT NEWSLETTER JULY 2008 We are finally starting to see some sunshine and hopefully we will all benefit from the warmer weather. I would like to take this opportunity to remind
More informationCAR ADAPTATION ASSESSMENT APPLICATION FORM. If you are unsure if this is the appropriate assessment, please ring to discuss.
Sent/Initials... QEF Mobility Services 1 Metcalfe Avenue, Carshalton Surrey, SM5 4AW Tel: 020 87701151 Fax: 020 8770 1211 Email: mobility@qef.org.uk www.qef.org.uk achieving goals for life CAR ADAPTATION
More informationSample Give and Let Live survey questions
Sample Give and Let Live survey questions Here are some closed questions you might think about using in your questionnaire. The questions you ask will depend on who your target audience is if everyone
More informationData capture form for telephone application
PERSONAL MENU PLAN Data capture form for telephone application Information for advisers how to use our telephone application service To apply for a Royal London Personal Menu Plan, simply go to adviser.royallondon.com
More informationSharing Healthcare Records
Summary Care Record has been used by healthcare professionals for a number of years records a summary of key health information these records enable healthcare professionals to treat you safely if you
More informationTHE SURGERY. 22 Castelnau Barnes London SW13 9RU. Telephone: 020 8748 7574 Facsimile: 020 8563 8821. Website: www.barnessurgery.co.
THE SURGERY 22 Castelnau Barnes London SW13 9RU Telephone: 020 8748 7574 Facsimile: 020 8563 8821 Website: www.barnessurgery.co.uk Welcome to our Practice. We aim to offer a full range of health services
More informationESTOVER SURGERY PRACTICE LEAFLET
ESTOVER SURGERY PRACTICE LEAFLET Estover Surgery Dr s R Olaiya & M Hamal Estover Health Centre Leypark Walk Estover Plymouth PL6 8UE Tel: 01752 789030 Fax: 01752 772665 Email: estover.surgery@nhs.net Website:
More informationCompensation for a personal injury following a period of abuse (physical and/or sexual)
Criminal Injuries Compensation Authority Tay House 300 Bath Street Glasgow, G2 4LN Freephone: 0800 358 3601 For office use only Reference number: Compensation for a personal injury following a period of
More informationPolicies and Procedures
NHS Blood and Transplant Policies and Procedures Information Charter [POL13] 2 Policy Reference Title Approved by This document replaces version issued June 2008 [POL13] NHSBT Information Charter Information
More informationInformation about how to pay compliments, raise concerns or complain about services at Lancashire Teaching Hospitals NHS Foundation Trust
Information about how to pay compliments, raise concerns or complain about services at Lancashire Teaching Hospitals NHS Foundation Trust This leaflet provides practical information on how you can provide
More informationswine flu vaccination:
swine flu vaccination: what you need to know Flu. Protect yourself and others. Contents What is swine flu?............... 3 About the swine flu vaccine....... 4 What else do I need to know?...... 8 What
More informationAnnex C Arden, Herefordshire and Worcestershire Area Team Patient Participation Enhanced Service 2014/15 Reporting Template
Arden, Herefordshire and Worcestershire Area Team Patient Participation Enhanced Service 2014/15 Reporting Template Practice Name: Whitehall Medical Practice Practice Code: M84004 1. Prerequisite of Enhanced
More informationBRECHIN MEDICAL PRACTICE. Practice Information Booklet
BRECHIN MEDICAL PRACTICE Practice Information Booklet WELCOME to Brechin Medical Practice. We hope this booklet will give you all the information that you require about the services provided by our Primary
More informationThis booklet answers the questions you may have about registering with your local GP. Why you should register with your local GP NHS GRAMPIAN
This booklet answers the questions you may have about registering with your local GP Why you should register with your local GP NHS GRAMPIAN Do you have difficulty understanding the English language? If
More informationBody, Brain and Tissue Donation Pack
Body, Brain and Tissue Donation Pack Information on donating your body, brain or tissue for anatomical examination, research or education and training Contents 3 Donation and the Human Tissue Authority
More informationViewing my Electronic Health Record
Viewing my Electronic Health Record An Introduction for Patients Online Electronic Health Record Empowering and Educating Patients Patient Information Guide Supported By Greater Huddersfield Clinical Commissioning
More informationAPPLICATION FOR FINANCIAL ASSISTANCE
APPLICATION FOR FINANCIAL ASSISTANCE ALTERNATIVELY APPLY ONLINE VIA THE FUND S WEBSITE WWW.NPOWERENERGYFUND.COM BEFORE COMPLETING THE APPLICATION FORM, PLEASE CAREFULLY READ THE NOTES BELOW. When you have
More informationA Guide for Patients of Abington Park Surgery
A Guide for Patients of Abington Park Surgery This guide covers the following topics: About SystmOnline Logging in to SystmOnline Changing/Resetting Your Password Logging Out of SystmOnline Managing Appointments
More informationCarer s Allowance Claim form
Carer s Allowance Claim form i Only use this form to claim Carer s Allowance if you are getting State Pension l Use this form to claim Carer s Allowance. l Please read the tes that came with the claim
More informationLearning Agreement 2015-2016
FOR OFFICE USE ONLY Student ID No. Learning Agreement 2015 2016 Employer/Sponsor On completion of this form, it must be signed and returned to the Student Advice Centre. Bath College, Avon Street, Bath,
More informationHolme Bubwith Medical Group Information for Patients Services at:
Useful Contacts Emergency Ambulance Service 999 Out of hours Service 0845 056 80 60 NHS Direct 0845 46 47 Holme On Spalding Moor Surgery 01430 860221 Bubwith Surgery 01757 288315 East Riding of Yorkshire
More informationLeicester Charity Link Grant application form
Leicester Charity Link Grant application form Client reference (for office use only) 20a Millstone Lane, Leicester LE1 5JN t: 0116 222 2200 f: 0116 222 2201 w: www.charity-link.org e: info@charity-link.org
More informationCivic Government (Scotland) Act 1982
Corporate Resources Legal Services Civic Government (Scotland) Act 1982 Application pack to substitute a vehicle for that designated as a taxi licence or a private-hire car licence This application pack
More informationSTOPPING DRINKING WITHOUT MEDICATION. Client Registration & Information Pack
STOPPING DRINKING WITHOUT MEDICATION Client Registration & Information Pack CONSENT CONTRACT FEEDBACK COMPLAINTS INSTRUCTIONS PLEASE EITHER: Complete and save and email to me (mark@markjay.co.uk), printing
More informationStandard Reporting Template Patient Participation DES 2014/15. Surrey & Sussex Area Team
Standard Reporting Template Patient Participation DES 2014/15 Surrey & Sussex Area Team Practice Name Practice Code Ash Vale Health Centre H81013 Signed on behalf of practice Jon Fox Date 30 th March 2015
More informationAPPLICATION FORM. Right Guard Security UK Ltd act as Managing Agents for Payroll Workshop Ltd to manage their employees on their behalf.
APPLICATION FORM Right Guard Security UK Ltd is an expanding company that has a vast range of security services. We are dedicated to providing an excellent service through highly trained, loyal and committed
More informationPlease note: only original documents accepted
HACKNEY CARRIAGE/PRIVATE HIRE DRIVER S LICENCE CHECKLIST Please note: only original documents accepted Applicants Use LSU Use ONLY Initials & Date LO Use ONLY Initials & Date Application form fully completed
More informationPLANNING FUTURE CARE. Wishes & Preferences for My Future Care. This Plan belongs to:
PLANNING FUTURE CARE Wishes & Preferences for My Future Care This Plan belongs to: Planning Your Future Care What is this Plan for? This Care Plan is your opportunity to think ahead and write down what
More informationHousing List Application
Answer all questions on this form fully & truthfully or your application will be delayed. Please use a black pen and write in BLOCK CAPITALS. If you need help filling in this form please contact 020 7364
More informationHOW YOU CAN OBTAIN ACCESS TO YOUR PERSONAL RECORDS Notes to accompany Application Form
HOW YOU CAN OBTAIN ACCESS TO YOUR PERSONAL RECORDS Notes to accompany Application Form Your right to request access to your personal records: The gives living individuals the right to request access to
More informationWIGAN COUNCIL'S CCTV SURVEILLANCE SYSTEM
WIGAN COUNCIL'S CCTV SURVEILLANCE SYSTEM This document contains advice and information for the general public regarding data recorded by Wigan Council's CCTV Systems and the provisions of the Data Protection
More informationFURTHER EDUCATION Place of education Type of training Qualification
APPLICATION FORM POSITION APPLIED FOR HOW DID YOU HEAR OF THIS VACANCY? (Name of publication, web site, agency or source) PERSONAL DETAILS Surname: First Names: Title: Previous Names: Home Address: Post
More informationGRANVILLE HOUSE MEDICAL CENTRE ANNUAL REPORT 2014/15
GRANVILLE HOUSE MEDICAL CENTRE ANNUAL REPORT 2014/15 Granville House is a long established practice working from a purpose built surgery covering the areas of Adlington, Anderton, Heath Charnock and Rivington.
More informationApplication Form ONLY APPLICATIONS SUBMITTED ON THIS FORM WILL BE PROCESSED BY THE OFFICER
Application Form ONLY APPLICATIONS SUBMITTED ON THIS FORM WILL BE PROCESSED BY THE OFFICER Applicant s details Loan Member Amount of loan Repayment Terms X w/f/m Cheque /Cash Loan Approved/Refused Payment
More informationHUDDERSFIELD ROAD SURGERY PATIENT PARTICIPATION REPORT YEAR ENDING 31 MARCH 2014
HUDDERSFIELD ROAD SURGERY PATIENT PARTICIPATION REPORT YEAR ENDING 31 MARCH 2014 The Practice has two surgeries: Huddersfield Road Surgery at 6 Huddersfield Road, Barnsley. Barugh Green Surgery at 44 Cawthorne
More informationRegistration Form National Housing Trust properties at The Glen Coalsnaughton
Ochil View Housing Association Ochil House Marshill Alloa FK101AB 01259 722899 customerservices@ochilviewha.co.uk Registration Form National Housing Trust properties at The Glen Coalsnaughton Mid-market
More informationHow to complain about a doctor
How to complain about a doctor England This booklet is for patients in England. Our procedures are the same throughout the UK, but healthcare and support organisations do vary. We have therefore also produced
More informationApplication Form 2016 entry
UK/EU applicants Application Form 2016 entry Use this form to apply for the following courses only: BA (Honours): Acting; Community Drama; Music, Theatre and Entertainment Management and Sound Technology.
More informationISA full encashment or partial withdrawal request form
ISA full encashment or partial withdrawal request form For use with Sterling ISAs only Alternatives to encashing your account You should only consider encashing your account if you have carefully reviewed
More informationKingsway Medical Centre Kingsway, Billingham, Cleveland, TS23 2LS
Kingsway Medical Centre Kingsway, Billingham, Cleveland, TS23 2LS Appointments & Emergencies Tel : 01642 553738 For Results & General Enquiries : Tel : 01642 554967 Please visit our surgery website for
More informationSubject Access Request Policy Number ID ID # 2011 075 Author: Nicola Bateman Author Job Title: Information Governance Manager Division: Corporate Department: Clinical Informatics Version Number: 2.1 Ratifying
More informationPatient Participation Reporting Template 2014-2015
Patient Participation Reporting Template 2014-2015 Practice details: Minchinhampton Surgery Stage one validate that the patient group is representative Demonstrates that the PRG is representative by providing
More informationStandard Reporting Template
Standard Reporting Template Practice Name: Stillmoor House Medical Practice Practice Code: L82010 Devon, Cornwall and Isles of Scilly Area Team 2014/15 Patient Participation Enhanced Service Reporting
More information