Reception: Register as a new patient

Welcome to Whitnash Medical Centre. Please print off this form or complete the form below to register yourself with the practice. We offer all patients, registering with the Practice, a “new patient consultation”. We strongly recommend that you make an appointment because the information gained at this meeting and through the questionnaire, helps us to provide you with the best care and attention possible.

Please see the links below on a variety of topics related to this form

Online access

Catchment area

Summary Care Record

Practice Privacy Notice

Please do not write any clinical queries on this form. Any clinical queries or request for appointments via this form will be discarded. To make an appointment either book online via the NHS app/Patient access or by calling reception 01926 316711. We will start to process your form by the next working day but it will take up to 5 working days to complete. Please DO NOT call before 5 working days as you will not receive a status update from reception or the administrative team. If you are NOT a registered patient then your form will be discarded. This service is only for patients registered at the surgery aged 16 and over; and for parents or legal guardians of children. Forms must be completed in the UK due to GDPR regulations.

Reception: Register as a new patient

Title

Surname:

First names:

Previous surname/s (if applicable)

Date of Birth (DD/MM/YYYY):

NHS No.Need help finding your NHS number: https://www.nhs.uk/using-the-nhs/about-the-nhs/what-is-an-nhs-number/

Gender

Town and country of birth

Home Address:

Postcode:

Telephone number:

Email Address:

We will need to trace your previous medical records so please provide us with 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 (Leave this section blank if this does not apply)

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 same doctor as me, for Child Health Surveillance

NHS Organ Donor Registration

I would like to join the NHS Organ Register as someone whose organs may be used for transplantation after my death. Please select as appropriate:

I confirm my agreement to organ/tissue donation.

For more information visit www.uktransplant.org.uk or call 03001232323

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

My preferred address including postcode for donation is: (Only if different from above, e.g. your place of work)

For all patients who are NOT ordinarily resident in the UK (Please leave this section blank if this does not apply to you)

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 pract

Please tick one of the following boxes:

I understand that I may need to pay for NHS treatment outside of the GP practice

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 requested

I do not know my chargeable status

Non-UK European Health Insurance Card (EHIC) or Provisional Replacement Certificate (PRC) (Please leave blank if not applicable)

Country Code

Name:

Given Names:

Personal Identification Number:

Identification number of the institution:

Identification number of the card

Expiry Date

PRC Valid From

PRC Valid To

S1 form (please leave blank if not applicable)

I have an S1 Form (e.g. 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 practice staff.

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.

Carer Status

Do you have a Carer?

If yes - please give name and contact telephone number

Are you a Carer?

If yes - please give name, relationship to you & contact number (Only with permission & not as part of your employment)

Is this person a patient at the Practice?

Are you happy for our Care Administrator to contact you?

Major Operations

I have not had any operations in the past.

If you have had past operation. Please outline them below (name & date)

Admission to hospital

Have you ever been admitted to hospital?

If you have been admitted to hospital in the past please outline why, where & when

Family Medical History

High Cholesterol of 7.5 or greater

If so, which member of the family?

Heart Attack

If so, which member of your family? How old were they when they had the heart attack?

If you selected other please specify

Drugs & Medicines

Are you being prescribed medication on a repeat basisIf you are taking any immunosuppressant medication or other medication prescribed to you by a specialist or a private provider, please be aware that Local Prescribing Guidelines and policies may mean that your GP Surgery cannot prescribe these medications

Do you have any allergies?If yes please state below

If yes, please state

Do you take Aspirin regularly, which you buy over the counter?

Lifestyle

What is your current smoking status?

How often do you have a drink that contains alcohol?

How many units of alcohol do you have on a typical day when you are drinking?

How often do you have 6 or more standard drinks on one occasion?Please add your scores together from the previous 3 questions - A total of 5+ indicates increasing or higher risk drinking. If you score 5+ we recommend that you make an appointment with one of our nursing team.

Exercise:

Diet:

Height:

Weight:

Immunisations

Tetanus

Please give the date (year will suffice) and stage ie booster etc.

Combined Diphtheria/Tetanus

Please give the date (year will suffice) and stage ie booster etc.

Polio

Please give the date (year will suffice) and stage ie booster etc.

Flu

Date (Year will suffice):

Pneumococcal (Pneumovax)

White

Date (year will suffice)

For Women

Form of contraception used:

Ethnicity

White

Mixed

Asian

Black or Black British

Other

Religious Beliefs

Please select which best applies to you:

Sexual Identity

Please select the most appropriate option:

Consent to communicating with you

To ensure that we comply with the new General Data Protection Regulations we need to ensure that you consent to the way we contact you and would appreciate it if you could complete the following questions.

MOBILE COMMUNICATION

We will use the mobile number supplied by you for this communication, so please consider if this is shared with others.

It is your responsibility to advise us of changes to your mobile phone number.

I consent to Whitnash Medical Centre contacting me via SMS (text) messaging to remind me of booked appointments and to advise me regarding services offered relating to my healthcare.

EMAIL COMMUNICATION

We will use the email address supplied by you for this communication, so please consider if this is shared with others.

It is your responsibility to advise us of changes to your email address.

I consent to Whitnash Medical Centre contacting me via email messaging to advise me regarding services offered relating to my healthcare.

Summary Care Record (SCR)

PLEASE ENSURE THAT YOU HAVE READ THE INFORMATION LINKED ABOVE WITH REGARDS TO YOUR SUMMARY CARE RECORD

If you decided to proceed, but at any time in the future you choose not to have a Summary Care Record, all you need do is write to your Surgery informing them of your decision to “Opt-out”. If you have already told your Surgery that you wish to “Opt-out” and you wish this to remain in place you need take no further action.

You do not have to have a Summary Care Record, although you are strongly recommended to consider this choice. Please select your option below.

I agree to my Summary Record to contain only core information

I agree to my Summary Care Record to contain Additional Information

I would like to Opt-out of my Summary Care Record

Accessible Information Standard

As part of the accessible information standard we wish to make sure that patients and service users, and their Carers and parents, can access and understand the information they are given by Whitnash Medical Centre.

If you have any information or communication needs- which relate to a disability, impairment or sensory loss. We can provide for instance letters in large print or Braille, or if you require an interpreter/ translator for consultations with the Doctor or Nurse.

Do you need a format other than standard print:

Do you need anyone to come to appointments with you:

Do you have any special communication requirements?

Do you consent to sharing the above information with other Health Care Professionals as your Doctor feels appropriate?

Application for online access to my medical record

Please ensure that you have read through the information linked at the top of the page with regards to online access.

Do you consent to us sharing your information with a third party in order for us to facilitate your needs as you have requested above?

1. I have read and understood the information leaflet provided by the practice

2. I will be responsible for the security of the information that I see or download

3. If I choose to share my information with anyone else, this is at my own risk

4. I will contact the practice as soon as possible if I suspect that my account has been accessed by someone without my agreement

5. If I see information in my record that is not about me or is inaccurate, I will contact the practice as soon as possible

I wish to have access to the following online services (please tick all that apply):

Booking appointments

Requesting repeat prescriptions

Accessing my Summary of Medical Record

Electronic Prescription Service (EPS)

If you have nominated a Pharmacy previously using this system and then recently joined our Practice – please ensure that your nominated Pharmacy is up to date – either with the Practice or your new Pharmacy of your choice.

For more information on the Electronic Prescription Service visit – www.connectingforhealth.nhs.uk/eps

If you wish to use the Electronic Prescription Service – please ask at your local Pharmacy or at Reception at Whitnash Medical Centre.

Please complete the Nomination form below to enable us to update your records if you wish to use this service.

My chosen pharmacy is:

I wish to access my medical record online and understand and agree with each of the above statements outlined 1-5.

If other state belowState name & postcode

Marital status

Occupation

Privacy Protection

Information submitted through secure forms is used only for the purposes of processing your request. We may be in touch with you in relation to the information submitted.

All Information submitted through secure forms is secured with a private key and is accessed over a secure connection by nominated staff. We have a strict confidentiality policy.

This information is not shared with any third party organisations.

This information is retained for up to 28 days.

I consent to my information being used for the purposes described above and wish to submit this online form to Whitnash Medical Centre • 110 Coppice Road , Whitnash, Warwickshire, CV31 2LT.

Learn more about our Privacy Policy and Terms of Use. Should you have any concerns about sending your personal details using the web, please use one of the alternative methods offered by our organisation.

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Reception: Register as a new patient

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