Family 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 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 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* I live more than 1 mile in a straight line from the nearest chemist I would have serious difficulty in getting them from a chemist *Not all doctors are authorised to dispense medicines Signature of Patient Signature on behalf of patient Date Version 01/02 Please see overleaf re: Organ donation

Family doctor services registration GMS1 NHSOrgan Donor registration I would like to join the NHS Organ Donor Register as someone whose organs may be used for transplantation after my death. Please tick as appropriate Kidneys Heart Liver Corneas Lungs Pancreas Any part of my body Signature confirming consent to organ donation Date For more information, please ask for the leaflet on joining the NHS Organ Donor Register NHSBlood Donor registration I would like to join the NHS Blood Donor Register as someone who may be contacted and would be pre p a red 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) To be completed by the doctor Postcode: 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 CHSlist 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

WESTCOURT MEDICAL CENTRE 12, The Street Rustington West Sussex BN16 3NX ELECTRONIC COMMUNICATION - CONSENT FORM Dear Patient, We are currently looking at different ways of communicating with our patients. At the present time these include text messages and emails. If you are happy for us to communicate with you electronically please: read this document carefully; select the services you wish to opt in to, and; complete your personal information and sign the declaration. ************************************************************************************************** EMAIL COMMUNICATION We are considering emailing specific patient groups the results of assorted tests. You will be advised if this is available to you. Would you be willing to receive this information via email? YES NO ************************************************************************************************** TEXT MESSAGING We are able to contact you via text message with appointment confirmations and reminders. Would you be willing to receive this information via text message? YES NO ************************************************************************************************** PATIENT PARTICIPATION We want to ensure that the views of patients are fed back to the surgery regarding the services we currently deliver and on potential future services, via an online Patient Participation Group. Are you interested in giving your feedback to the surgery online? YES NO We are looking into the possibility of producing a patient newsletter four times a year, containing updates on the surgery, health advice and general news. This can either be collected from our reception desk or emailed to patients. Are you interested in receiving the electronic newsletter via email? YES NO

DECLARATION I consent to the surgery contacting me by electronic communication for the purposes of health advice, appointment confirmation and reminders, as indicated by my preferences on the front page of this document. I understand that some services are in addition to normal practices and therefore may not take place on all occasions. I acknowledge that the responsibility of attending appointments, or cancelling them, still rests with me. I understand that the surgery does not offer a reply facility to enable patients to respond to texts directly. Emails and text messages are generated using a secure facility however I understand: that texts are transmitted over a public network onto a personal telephone and as such may not be secure, however the practice will not transmit any information which would enable an individual patient to be identified; and that there may be confidential information included in test results received via email, and I am happy for this to be sent to the email address provided. I agree to advise the surgery if my email address and/or mobile number changes, or if they are no longer in use. I understand that I can cancel the electronic communication facility at any time by contacting Westcourt. Name Date of Birth Email Address Patient Signature Mobile Phone Number Date of Signature Please return your completed form to Reception.

RECEPTION Please ensure a blood pressure slip is stapled here NEW PATIENT HEALTH QUESTIONNAIRE Please complete this questionnaire and return to the surgery at your earliest convenience Thank you for your co-operation. Name: Address: Date of Birth: Postcode: Have you had any serious illnesses? (e.g. pneumonia, heart attack, broken hip) YES/NO ILLNESS YEAR/DATE Have you had any operations or are you on a waiting list? YES/NO OPERATION YEAR/DATE Are you currently receiving treatment for an ongoing medical problem? YES/NO PROBLEM YEAR OF ONSET TREATMENT Are you allergic to any medication? YES/NO DETAILS Family History (blood relatives)? YES/NO RELATIONSHIP MEDICAL PROBLEM CARERS/NEXT OF KIN Do you care for someone with a physical or mental illness or a disability? YES/NO If so, please tick the box if you would like to be added to the Carer s Register at the surgery and receive information about the Carers Support Service. Are you looked after by a Carer? Yes/No Next of kin. A carer is a person who spends a significant proportion of their life caring for a relative, partner or friend who is ill, frail, disabled or has a mental health problem.

LIFESTYLE? Occupation Diet Blood Pressure (Please use Blood pressure machine in the treatment room waiting area at the surgery) Weight Height SMOKING Do you smoke? YES/NO If so how many per day? If Yes have you ever considered giving up? Are you an ex-smoker? If so when did you give up? ALCOHOL Please consider the questions below:- Alcohol Users Disorders Identification Test (Audit) C Questions How Often do you have a drink that contains alcohol? How many standard alcoholic drinks do you have on a typical day when you are drinking? How often do you have 6 or more standard drinks on one occasion Scoring System O 1 2 3 4 2-4 2-3 4+ Monthly times times times Never or less per per per month week week N/A 1-2 3-4 5-6 7-9 10+ N/A Never Less than monthly Monthly Weekly Daily or almost daily Your Score Scoring: A total of 5+ indicates hazardous or harmful drinking STANDARD ALCOHOLIC DRINK IS:- Pint of regular Alcopop or Glass of wine Single measure of Bottle of Beer/lager/cider Can of Lager 175ml) spirits wine 2 UNITS 1.5 UNITS 2 UNITS 1 UNIT 10 UNITS

PATIENT ETHNIC ORIGIN QUESTIONNAIRE Please answer the following two questions. This is not compulsory, but may help with your healthcare, as some health problems are more common in specific communities, and knowing your origins may help with the early identification of some of these conditions. Indicate main language spoken and choose ONE from section A to Z. Name.DOB.. Question 1 Main Language spoken Question 2 White A B C Mixed D E F G British Irish Any other white background White and Black Caribbean White and Black African White and Asian Any other mixed background Asian or Asian British H Indian J Pakistani K Bangladeshi L Any other Asian background Black or Black British M Caribbean N African P Any other black background Other ethnic group R Chinese S Any other Z Not stated PLEASE RETURN TO WESTCOURT MEDICAL CENTRE THANK YOU

Physical Activity at Work Please let us know the type and amount of physical activity involved in your work. Please tick one box that is closest to your present work from the following five possibilities o I am not in employment (eg retired, retired for health reasons, unemployed, full-time carer etc. o I spend most of my time at work sitting (such as in an office) o I spend most of my time at work standing or walking. However, my work does not require much intense physical effort (eg shop assistant, hairdresser, security guard, childminder etc.) o My work involves definite physical effort including handling of heavy objects and use of tools (eg plumber, electrician, carpenter, cleaner, hospital nurse, gardener, postal delivery workers etc.) o My work involves vigorous physical activity including handling of very heavy objects (eg scaffolder, construction worker, refuse collector etc.) Physical Exercise During the last week, how many hours did you spend on each of the following activities? Please circle appropriate answer a.physical exercise such as swimming, None Less than between 1-3 3 or more Jogging, aerobics, football, tennis 1 hour hours hours Gym work out etc. b.cycling, including cycling to work None Less than between 1-3 3 or more and during leisure time 1 hour hours hours c.walking, including walking to work None Less than between 1-3 3 or more Shopping, for pleasure etc. 1 hour hours hours d.housework/childcare None Less than between 1-3 3 or more 1 hour hours hours e.gardening/diy None Less than between 1-3 3 or more 1 hour hours hours Walking pace How would you describe your usual walking pace? Please circle appropriate answer Slow pace Steady average pace Brisk pace Fast pace (less than 3mph) (over 4mph) Please complete and bring with you to your appointment. Thank you for your time and co-operation.

Your emergency care summary Dear Patient Summary Care Record your emergency care summary The NHS in England is introducing the Summary Care Record, which will be used in emergency care. The record will contain information about any medicines you are taking, allergies you suffer from and any bad reactions to medicines you have had to ensure those caring for you have enough information to treat you safely. Your Summary Care Record will be available to authorised healthcare staff providing your care anywhere in England, but they will ask your permission before they look at it. This means that if you have an accident or become ill, the doctors treating you will have immediate access to important information about your health. Your GP practice is supporting Summary Care Records and as a patient you have a choice: Yes I would like a Summary Care Record you do not need to do anything and a Summary Care Record will be created for you. No I do not want a Summary Care Record enclosed is an opt out form. Please complete the form and hand it to a member of the GP practice staff. If you need more time to make your choice you should let your GP Practice know. For more information talk to our Customer Service Unit (CSU) (0300 100 1821), GP practice staff, visit www.westsussex.nhs.uk/summary-care-records or www.nhscarerecords.nhs.uk or telephone the dedicated NHS Summary Care Record Information Line on 0300 123 3020. Additional copies of the opt out form can be collected from the GP practice, printed from the website www.nhscarerecords.nhs.uk or requested from the dedicated NHS Summary Care Record Information Line on 0300 123 3020. You can choose not to have a Summary Care Record and you can change your mind at any time by informing your GP practice. If you do nothing we will assume that you are happy with these changes and create a Summary Care Record for you. Children under 16 will automatically have a Summary Care Record created for them unless their parent or guardian chooses to opt them out. If you are the parent or guardian of a child under 16 and feel that they are old enough to understand, then you should make this information available to them. Yours sincerely Signed : Practice Manager

Your emergency care summary CONFIDENTIAL OPT-OUT FORM Request for my clinical information to be withheld from the Summary Care Record If you DO NOT want a Summary Care Record please fill out the form and send it to your GP practice (completed forms must be returned to your GP practice. Forms sent anywhere other than your GP practice will not be actioned). A. Please complete in BLOCK CAPITALS Title... Surname / Family name... Forename(s)... Address... Postcode... Phone No... Date of birth... NHS number (if known)... Signature... B. If you are filling out this form on behalf of another person or child, their GP practice will consider this request. Please ensure you fill out their details in section A and your details in section B Your name... Your signature... Relationship to patient... Date... What does it mean if I DO NOT have a Summary Care Record? NHS healthcare staff caring for you may not be aware of your current medications, allergies you suffer from and any bad reactions to medicines you have had, in order to treat you safely in an emergency. Your records will stay as they are now with information being shared by letter, email, fax or phone. If you have any questions, or if you want to discuss your choices, please: phone the Summary Care Record Information Line on 0300 123 3020; contact your local Patient Advice Liaison Service (PALS); or contact your GP practice. FOR NHS USE ONLY Actioned by practice yes/no... Date... Ref: 4705 Opt_Out_V2.indd 1 30/08/2011 15:48

WESTCOURT MEDICAL CENTRE CARE.DATA OPT OUT FORM Request for personal confidential data to be withheld from the HSCIC care.data upload For the person named below. Please use one form per person. Title Forename(s) Surname Address Preferred Phone Number Date of Birth NHS Number (if known) Patient s Signature Date If you are filling this form out on behalf of a child please also complete the section below: Your name Your signature Relationship to Patient Date Please tick as appropriate (you can opt out of both or individual components): I do not want my personal confidential data to leave the GP Practice I do not want my personal confidential data to leave the Health and Social Care Information Centre (HSCIC) For Practice Use Only: XaZ89 YES / NO XaaVL YES / NO Date: Initials:

Westcourt Medical Centre Patient Registration Form SystmOnline Services Patient s Details (please print clearly) Surname First Name Date of Birth NHS Number (if known) Full Address (inc. postcode) Email Address Mobile Number I would like to register for online appointments and repeat prescriptions Yes No I would like to receive appointment reminders by text Yes No I would like to access my Summary Care Record online Yes No I would like to receive communication by email Yes No I confirm that I give permission for the Practice to register me for online services and to communicate via the agreed methods above. Signature Date ONLINE SERVICES - Westcourt Medical Centre, 12 The Street, Rustington, West Sussex, BN16 3NX.

Westcourt Medical Centre Consent for Online Access to Medical Records You can now view your GP medical record online. If you would like to have secure online access to your records, we need to make sure that you understand what this involves and that you are happy for us to use the information about you (provided below) to set up the and operate the service. The following form will take you through the things you need to think about. By signing the attached consent form you will be giving us your permission to go ahead with setting up the service for you. If you decide not to join, or wish to withdraw, it will not affect your treatment in any way. At the moment you can view allergies & adverse reactions, acute medications, current repeat medications and discontinued repeat medications. In the future more detailed information may become available; you will not need to sign another access form. Declaration (please delete response as appropriate): 1. I agree to my GP practice giving me access to my record online. YES / NO 2. I have read and understood the information about access to GP medical records. 3. I agree to use the system in a responsible manner in accordance with all instructions given to me by the practice. If not access may be withdrawn. 4. If I see information which does not relate to me, I will immediately log out and report the matter to the practice as soon as possible. 5. I agree that it is my responsibility to keep my username and password secure. If I think these have been shared inappropriately I will reset them using the instructions supplied. I am also responsible for keeping safe any information I may print from the record. 6. I agree that my details below may be used to contact me about how useful I find the service and whether it could be improved. 7. I understand that online access is granted at the discretion of the practice, taking into account my best interests. I will be informed of any decision to withdraw the service. Please note, this does not affect your rights of Subject Access under the Data Protection Act. ONLINE SERVICES - Westcourt Medical Centre, 12 The Street, Rustington, West Sussex, BN16 3NX. YES / NO YES / NO YES / NO YES / NO YES / NO YES / NO Other considerations The practice makes every effort to record information as accurately as possible, however there may be information that you do not feel is correct. 8. If I notice any inaccuracies with my record, I will inform a senior member of YES/NO staff as soon as possible of any errors or omissions. 9. I understand that I may see information on my record that I was unaware of / have forgotten about that could cause distress. 10. I understand that as before, I will be informed directly, by the practice, of any test results which require further action. However I understand that I may, in the future, see these results online before the practice has been able to contact me. This could be while the surgery is closed and there is no one available to discuss them with me. YES / NO YES / NO

Please remember to keep all your account details secure. If you think your account details may have been shared you should reset them straight away. If you have any queries or concerns about the service or wish to withdraw from the service please ask to speak with the Reception Team Lead. For practice use only: List ID Checked Whom by Date Authorised by GP Date Patient Access Activated by Date ONLINE SERVICES - Westcourt Medical Centre, 12 The Street, Rustington, West Sussex, BN16 3NX.

A new way to get your medicines and appliances The Electronic Prescription Service (EPS) is an NHS service. It gives you the chance to change how your GP sends your prescription to the place you choose to get your medicines or appliances from. What does this mean for you? If you collect your repeat prescriptions from your GP you will not have to visit your GP practice to pick up your paper prescription. Instead, your GP will send it electronically to the place you choose, saving you time. You will have more choice about where to get your medicines from because they can be collected from a pharmacy near to where you live, work or shop. You may not have to wait as long at the pharmacy as there will be time for your repeat prescriptions to be ready before you arrive. Is this service right for you? Yes, if you have a stable condition and you: don t want to go to your GP practice every time to collect your repeat prescription. collect your medicines from the same place most of the time or use a prescription collection service now. It may not be if you: don t get prescriptions very often. pick up your medicines from different places. How can you use EPS? You need to choose a place for your GP practice to electronically send your prescription to. This is called nomination. You can choose: a pharmacy. a dispensing appliance contractor (if you use one). your dispensing GP practice (if you are eligible). Ask any pharmacy or dispensing appliance contractor that offers EPS or your GP practice to add your nomination for you. You don t need a computer to do this. Can I change my nomination or cancel it and get a paper prescription? Yes you can. If you don t want your prescription to be sent electronically tell your GP. If you want to change or cancel your nomination speak to any pharmacist or dispensing appliance contractor that offers EPS, or your GP practice. Tell them before your next prescription is due or your prescription may be sent to the wrong place. Is EPS reliable, secure and confidential? Yes. Your electronic prescription will be seen by the same people in GP practices, pharmacies and NHS prescription payment and fraud agencies that see your paper prescription now. Sometimes dispensers may see that you have nominated another dispenser. For example, if you forget who you have nominated and ask them to check or, if you have nominated more than one dispenser. Dispensers will also see all the items on your reorder slip if you are on repeat prescriptions. For more information visit www.hscic.gov.uk/epspatients, your pharmacy or GP practice. April 2013 ref: 4742

WESTCOURT MEDICAL CENTRE 12 The Street Rustington West Sussex BN16 3NX NHS EPS Patient Nomination Request Name: Address: Telephone: Mobile: Postcode: Date of Birth: Gender: Male Female Email: NHS Number: This can be found at the top right of your prescription Please provide your name and address if you are a representative of the patient Full Name: Address: Telephone: Postcode: Name and Address of Nominated Dispenser: Postcode: Nomination has been explained to me by staff at my GP practice / community pharmacy / appliance contractor. I have retained the leaflet providing an overview of EPS and nomination and I understand what I have to do. I understand that EPS is an NHS-funded service and the Repeat Prescription Collection Service is a separate service run by the pharmacy. I confirm that I have made my nomination of my own free will and have not been influenced or given a gift to select a particular nomination. I am the patient I am the patient s parent / guardian I am the patient s representative Signed: Print Name: Date: Date Actioned & Staff Initials: \\H82007DC001\h82007-usf\~Vision-Server-Data\Global\Work\Registration Pack\EPS Nomination Form for Registration Pack.docx