Adults (Over 16's) Registration Form

Fields marked "REQUIRED" are compulsory. You should only send this form if you are sure that you are eligible to join this practice. Sending this form will NOT automatically register you with the surgery. Your details will be held at the surgery for a limited period of time. You are required to present in person to sign your registration form and provide proof of your address. Sending this form does NOT guarantee or even imply that you will be accepted onto the practice register.

Last Updated: 21/12/2023

Before completing this form

Are you on regular medication?

If so, please make sure that you request a repeat prescription from your current practice for all of the medication you need before you submit these forms. It could take up to two weeks for us to process your application and therefore it is essential that you are prepared for this.

Patient details

If you need help finding your NHS number for the question below, you can find it using the following web address: www.nhs.uk/find-nhs-number

Preferred Title (How would you like us to refer to you (e.g. Mr, Mrs, Miss, Mx)?

Surname *

Forename(s) *

Date of Birth (day/month/year) *

NHS number (if known)

Previous Surname(s)

Gender *

Place of birth (Town and Country) *

Home Address *

Postcode *

Telephone *

Mobile (if not used in the telephone section)

Email (must be unique)

We can email you our patient newsletter. Would you like us to add your email address to the recipient list? *

Yes No

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

Your previous address in UK *

Name of previous GP practice while at that address *

Address of previous GP practice *

If you are from abroad

There is also a section of supplementary questions at the bottom of this form for you to complete.

Your first UK address where registered with a GP

If previously resident in UK, date of leaving (Day/Month/Year)

Date you first came to live in UK (Day/Month/Year)

Service Families and Military Veterans

As a practice, we fully support the Armed Forces Covenant. We can only do this if we know our patients' connections to the Armed Forces.

These questions are optional and your answers will not affect your entitlement to register or receive services from the NHS but may improve access to some NHS priority and service charities services.

Patient details continued

These are details that will be helpful for the practice to know but are not crucial to your registration with us

Contacting you

We will use your contact details to send reminders about appointments, reviews, and other services which may be of benefit in your medical care

Do you consent to the surgery sending text messages to your mobile

Yes No

Are you interested in joining our Patient Participation Group (PPG)?

Yes No

Disabilities/Accessible Information Standards

As a practice we want to make sure that we give you information that is clear to you. For that reason we would like to know if you have any communication needs.

Medications

If you are on repeat medication, please book a telephone consult with one of our pharmacists to renew your prescriptions. The Abbottswood Medical Centre main number is 01386 552424

Has your GP requested that you take Aspirin

Yes No

Was Aspirin on your repeat prescription

Yes No

(or) Do you purchase Aspirin over the counter

Yes No

Do you take any over the counter medication? If so, please list

Electronic Prescribing Service (EPS)

The EPS allows prescribers - such as GPs and practice nurses to send prescriptions electronically to a dispenser (such as a pharmacy) of the patient's choice. This makes the prescribing and dispensing process more efficient and convenient for patients and staff. As a practice, we would encourage all patients to opt for electronic prescribing.

Even if you are not currently on medication, we ask that you complete this section so that if you are prescribed an acute or repeat medication your nomination is already set.

Please select one of the following *

I DO give consent for my prescriptions to be sent electronically to the pharmacy

I DO NOT give consent for my prescriptions to be sent electronically to the pharmacy

Nominated pharmacy: Name of pharmacy *

Nominated pharmacy: Town/City *

Nominated pharmacy: Postcode (if not a local pharmacy) *

Summary Care Record

If you are registered with a GP practice in England, you will already have a Summary Care Record (SCR), unless you have previously chosen not to have one. It will contain key information about the medicines you are taking, allergies you suffer from and any adverse reactions to medicines you have had in the past.

Information about your healthcare may not be routinely shared across different healthcare organisations and systems. You may need to be treated by health and care professionals who do not know your medical history. Essential details about your healthcare can be difficult to remember, particularly when you are unwell or have complex care needs.

Having a Summary Care Record can help by providing healthcare staff treating you with vital information from your health record. This will help the staff involved in your care make better and safer decisions about how best to treat you.

You have a choice

You have the choice of what information you would like to share and with whom. Authorised healthcare staff can only view your SCR with your permission. The information shared will solely be used for the benefit of your care.

Your options are outlined below;

· Express consent for medication, allergies and adverse reactions only. You wish to share information about medication, allergies and adverse reactions only.

· Express consent for medication, allergies, adverse reactions and additional information. You wish to share information about medication, allergies and adverse reactions and further medical information that includes: your illnesses and health problems, operations and vaccinations you have had in the past, how you would like to be treated (such as where you would prefer to receive care), what support you might need and who should be contacted for more information about you.

· Express dissent for Summary Care Record (opt out). Select this option, if you DO NOT want any information shared with other healthcare professionals involved in your care.

If you chose not to complete this consent section, a core Summary Care Record (SCR) will be created for you, which will contain only medications, allergies and adverse reactions.

You are free to change your decision at any time by informing your GP practice.

For more information, please visit https://www.digital.nhs.uk/summary-care-records/patients, call NHS Digital on 0300 303 5678 or speak to your GP Practice.

Please specify your Summary Care Record Preference (Please read the above information before making a decision so that you can choose the best option for you) *

Yes, I would like a summary care record. (Consent for medication, allergies and adverse reactions only)

Yes, I would like a summary care record. (Consent for medication, allergies, adverse reactions and additional information)

No, I would not like a summary care record. (Dissent for Summary Care Record (opt out))

Name of PATIENT *

Date of birth (Day/Month/Year) *

PATIENTs postcode *

Surgery name *

Surgery Location (Town) *

NHS number (If known)

Signature (Digital) *

Todays date (Day/Month/Year) *

Please provide your name below if you are filling out this form on behalf of another person, please ensure that you fill out their details above; you provide your digital signature above as well

If you are filling out this form on behalf of another person, what is your relationship to that person

Parent

Legal Guardian

Lasting power of attorney for health and welfare

Local Shared Electronic Health Record

Many areas of the country have a local shared electronic health record too. Giving healthcare staff access to this information can prevent mistakes being made when caring for you in an emergency or when your GP practice is closed. Are you happy for you record to be shared across organisations caring for you? (This is accessed by relevant staff for your direct care on a need-to-know basis only)

Are you happy to be part of the local shared electronic health care record? (If you select no, you need to be aware that NHS Healthcare staff may not be able to see important elements of your care history)

Yes No

Power of Attorney

If you have legally appointed a Power of Attorney (POA) for Health and Welfare, or Property and Affairs, then please provide us with a copy of the legal document. This means that relevant information can be disclosed to enable the POA to discharge their role as attorney or deputy.

Does anybody hold Lasting Power of Attorney for Health and Welfare for you *

Yes No

If you have a POA, please provide us with a copy so we can add them to your records. We will be unable to process any requests from your POA until we receive these.

Yes No

Preferred Priorities of Care and Advanced Decisions to Refuse Treatments (ADRT)

You may have had a discussion with your previous GP regarding a Do Not Resuscitate or ReSPECT form (Recommended Summary Plan for Emergency Care and Treatment) which is used to create personalised recommendations for a person’s clinical care and treatment in a future emergency in which they are unable to make or express choices.

If you have either of these in place then please provide us with a copy so we can make sure your medical records are up to date with your wishes.

If you wish to change any of your previous decisions then please contact reception.

ADRT - if you have a signed up to date ADRT then please also provide us with a copy of this for your preferences to be recorded on your medical records.

Vaccinations

Have you had a pneumonia vaccine

Yes No

If yes to the previous question, what date (Day/Month/Year)

Have you had a shingles vaccine

Yes No

If yes to the previous question, what date (Day/Month/Year)

Family history

Have any close relatives (parent, sibling, or child only) ever suffered from any of the following?

Please advise relationship of person.

Heart Disease (Heart attack/Angina)

Stroke

Diabetes

Asthma

Cancer

Have you yourself ever suffered from any important medical illness, operation or admission to hospital? If so please enter details below (What the condition is/was, The year you were diagnosed, and Is it ongoing)

Allergies: Please list any drug or food allergies that you have below

Did you have a blood transfusion before 1991

Yes No

Donation wishes

If you live in England, Wales, Jersey, are not in a group excluded from opt out legislation and you have not registered an organ donation decision, it will be considered that you agree to be an organ donor. This is known as deemed consent. If you do not want to donate your organs then you should register your decision to refuse to donate. Remember to speak to your family and loved ones about your decision. To opt out, visit: https://www.organdonation.nhs.uk/register-your-decision/do-not-donate/ or you can set your preference in the NHS App if you are signed up to it.

Height/Weight

If you would like advice on managing a healthy weight, please contact https://www.nhs.uk/live-well/ or reception who will be able to direct you to the most appropriate service.

What is your height

What is your weight

Smoking status

Smoking is the UK's single greatest cause of preventable illness. Stopping smoking is not easy but it can be done, and there is now a comprehensive, NHS Smoking Cessation Service offering support and help to smokers wanting to stop, with cessation aids available on NHS prescription.

If you would like help and advice on how to give up smoking, please contact https://www.nhs.uk/live-well/quit-smoking/ or ask reception.

Do you smoke

Yes No

If yes, how many cigarettes do you smoke daily

If no, have you smoked in the past

Yes No

Do you use electronic cigarettes/vape

Yes No

Alcohol intake

For the below questions you will need to add up your points which are based on your answers and their values shown in parentheses ()

Use the system below to help you calculate.

How much is 1 unit of alcohol?:

Half a pint of "regular" beer, lager, or cider

Half a small glass of wine

1 single measure of spirits

1 small glass of sherry

1 single measure of aperitifs

Drinks that are MORE than a single unit:

1 pint of "regular" beer, lager, or cider is about "2 units"

1 pint of "strong" or "premium" beer, lager, or cider is about "3 units"

Alcopop or a 275ml bottle of regular lager is about " 1.5 units"

A 440ml can of "regular" lager or cider is about "2 units"

A 440ml can of "super strength" lager or cider is about "4 units"

A 250ml glass of wine is about "3 units"

A 75cl bottle of wine is about "9 units"

If you would like help and advice on how to reduce your alcohol intake, please contact https://www.drinkaware.co.uk/ or ask at reception

Exercise

General Practice Physical Activity Questionnaire

How would you describe your weekly exercise regime? This includes but is not limited to work, housework, childcare, gardening, DIY, etc...

Exercise physically impossible

Trivial amounts of exercise (sedentary)

Light exercise

Moderate exercise

Heavy exercise

For female patients only

If you are between the ages of 25 to 49 you should receive invitations every 3 years. If you haven't had a cervical smear in over 3 years you should call to set up an appointment. If you are between the ages of 50 to 64 you should receive invitations every 5 years. If you haven't had a cervical smear in over 5 years you should call to set up an appointment.

Are you currently pregnant? If yes, please ensure you are under the care of a midwife. If you are NOT currently under the care of a midwife please speak to reception regarding this.

Yes No

Which method of contraception (if any) are you using at present

Do you currently have a long acting reversible contraception in place? (Implant/Coil)

Yes No

If yes to the previous question, when was it fitted (Day/Month/Year)

Have you had a cervical smear test

Yes No

If you have had a cervical smear test, when was it last done (Day/Month/Year)

Supplementary Questions (only to be completed if you are from abroad)

These questions and the patient declaration are optional and your answers will not affect your entitlement to register or receive services from your GP.

PATIENT DECLARATION for all patients who are not ordinarily resident in the UK

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 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.

I declare that the information I give on this form is correct and complete. I understand that if it is not correct, appropriate action may be taken against me.

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

Signed (digital signature)

Todays date (Day/Month/Year)

On behalf of (if you are a carer)

Your relationship to patient (if you are a carer)

EHIC (only to be completed if you are from abroad)

Complete this section if you live in an EU country, or have moved to the UK to study or retire, or if you live in the UK but work in another EEA member state. Do not complete this section if you have an EHIC issued by the UK.

NON-UK European Health Insurance Card (EHIC), Provisional Replacement Certificate (PRC) Details and S1 Forms

If you are visiting from another EEA country and do not hold a current EHIC (or Provisional Replacement Certificate (PRC))/S1, you may be billed for the cost of any treatment received outside of the GP practice, including at a hospital.

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 Business Service Authority for the purpose of recovering your NHS costs from your home country.

Do you have a non-UK EHIC or PRC? If yes, please answer the following 10 questions using the details from your EHIC or PRC

Yes No

1) Country Code

2) Name

3) Given Names

4) Date of Birth (Day/Month/Year)

5) Personal Identification Number

6) Identification number of the Institution

7) Identification number of the card

8) Expiry Date (Day/Month/Year)

9) PRC validity period (a)FROM (Day/Month/Year)

9) PRC validity period (b) TO (Day/Month/Year)

Please tick if you have an S1 (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) and provide you S1 form to the practice staff

I have an S1 form

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Adults (Over 16's) Registration Form

Are you on regular medication?

If so, please make sure that you request a repeat prescription from your current practice for all of the medication you need before you submit these forms. It could take up to two weeks for us to process your application and therefore it is essential that you are prepared for this.

Further Information

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