Checklist for Patient Registration (For office use only - aid for Reception staff) Checked patient lives in practice area Form signed and dated on page 4 Photo ID and Address ID checked (speak to reception manager if no ID available) Does the patient have any immediate health needs (see page 6)? Action take if they have immediate health needs: Does the patient have an EPS nomination? Is it still correct? Does the patient take Warfarin? See page 6 need to book INR appointment (30 mins) Does the patient require regular medication (see page 6)? Action taken if they require regular medication: New patient health check offered Booked (date) Declined Not ordinarily resident in UK (page 3) Complete supplementary questions on GMS1 form. Please ensure all boxes are ticked when accepting a new registration. Sign below and attach to registration documents. Receptionist Name Date Receptionist Signature Page 1 of 9
Acceptable Identification Documents for Registration at the Practice Please note that you need to provide 2 forms of identification 1 name identification AND 1 address identification Name Identification Current signed full passport Current UK driving licence Blue disabled drivers pass Current benefits or State Pension notification letter confirming rights to benefits for the current period Current HMRC tax notification e.g. PAYE coding, statement of account (P45 s & P60 s are not official HMRC documents) Shotgun or Firearms certificate Travel documents issued to foreign nationals granted permission to remain in the UK Current EU/EEA driving licence Residence permit issued by the Home Office to EU nationals EU/EEA member state identity card Address Identification Recent utility bill or statement showing current address in our area Local Authority tax bill for current year Bank or Building society statements Credit/store card statement Mortgage statement Local Council rent card Tenancy agreement Solicitors letter confirming recent purchase of your property Under 16 s Children under the age of 16 whose Parent/Guardian is registered with the Practice or registering at the same time will need to provide either: Original Birth Certificate or a certified copy Passport If you are unable to provide any of the above documents please speak to a member of the Reception team who will be able to advise you on how to register. We will not refuse to register anyone just because they do not have ID. Page 2 of 9
Rosebank Health Patient Registration Form GSM1 Patient Details NHS Number (we need this in order to register you)... Mr Mrs Miss Ms Other... Marital Status... Male Female Surname... First Name(s)... Previous Surname(s)... Date of Birth.../.../... Town and Country of Birth... Home address... Post Code... Home Phone Nr... Mobile Nr... Can we text message you? Yes No Can we leave answerphone messages for you? Yes Do you live in a care home or nursing home? Yes No No Please help us trace your previous medical records by providing the following information Your previous address in the UK... Name and address of your previous surgery... If you are from abroad Your first UK address where registered with a GP... Previous resident of UK, date of leaving..././. Date you first came to live in the UK..././. Are you ordinarily resident in the UK? Yes No (If not, you will need to complete the supplementary questions at the back of this form) Page 3 of 9
If you are returning from the Armed Forces Address before enlisting... Service/Personnel Nr... Enlistment date../.../... If you are registering a child under 5 I wish the child to be registered with the surgery for Child Health Surveillance. NHS Organ 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..././. 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) Patient please sign below Patient On behalf of patient... Date..././. Page 4 of 9
This information is not required in order to register you but it will help us meet your needs until your medical records are received from your previous surgery. About You Occupation:... Emergency Contact Information Emergency Contact Name/Next of Kin:... Relationship:... Their Contact Tel No:... Religion and Ethnic Group Religion:... Ethnic Group:... Lifestyle Height:... Weight:... Have you ever smoked? Yes No If Yes, are you now an ex-smoker? Yes No If you are a smoker, what is your daily consumption?... FAST Alcohol Screening Test 1 drink = ½ pint of beer, 1 small glass of wine or 1 single spirit How often have you had 6 or more drinks on one occasion in the last year? How often during the last year have you been unable to remember what happened the night before because you had been drinking? How often during the last year have you failed to do what was normally expected from you because of your drinking? Has a relative or friend, doctor or other health worker been concerned about your drinking or suggested that you cut down? Never Never Never No Less than monthly Less than monthly Less than monthly Monthly Monthly Monthly More than one Occasion Weekly Weekly Weekly Daily or almost daily Daily or almost daily Daily or almost daily On One Occasion Page 5 of 9
Medical Needs Please specify any medication you are allergic to:... Please tick if you are allergic to eggs / nuts / peanuts Do you have any immediate health needs? Yes No If so, what are they?... Do you take any regular medication? Yes No Please attach your most recent repeat medication reorder form to this form (you can get this from your previous GP). Please book a review with a GP as soon as possible. If you need a repeat prescription of any regular medication before you can see a doctor, please inform the reception team. Are you on Warfarin? Yes No If Yes please book 30 min INR appointment and bring your previous INR results with you Communication and Support Needs Are you registered disabled? Yes No If yes please state type of disability... Is English your first language? Yes No If not, please tell us what your first language is... Do you need a translator? Yes No Do you have any other communication needs? Yes No If so, how can we help you (please be as specific as possible e.g. BSL interpreter)?... Is there anything else we need to be aware of (e.g. phobias, cultural needs)?... Page 6 of 9
Carer Identification and Referral Form If you are a Carer or are cared for we would like to hold this information in your medical record. This will help us provide support as necessary and have a better understanding of your needs. By completing this form you agree that we can retain this information in your medical record. If you re a Carer who helps and supports someone who can t manage on their own, we want to ensure YOU get all the support YOU need. To be able to do this, we need to know certain facts about your caring situation, as listed in the form overleaf. If you re a carer, with your permission, we will refer you to Carers Gloucestershire, a countywide organisation providing relevant information and advice, local support services, newsletter and telephone help for carers. They are able to assess your needs (called a Carers Needs Assessment) and give you the chance to discuss your role as a Carer and what help you may need to: Support you as a Carer, Maintain your own health Balance caring with other aspects of your life. It s NOT about judging the way you are caring for someone, nor should social services assume that you wish to become, or carry on being, a Carer. As a result of completing the Assessment, the local authority may provide services to help you in your caring role or to maintain your own health and well-being. It can also look at the needs of the person you care for. This could be done separately, or together, depending on the situation. Carers Details: Your Name: Date of Birth: Section A I AM a Carer Your Address: Home Tel: I care for: Full Name: Mobile: Address: Contact Tel: Date of Birth: Relationship (if any) Is the person you care for registered with Rosebank Health? Yes No Please refer me to Carers Gloucestershire for a Needs Assessment Yes No Signed: Date: Page 7 of 9
Section B I HAVE a Carer Patient Details: Your Name: Date of Birth: Your Address: Home Tel: I am cared for by: Full Name: Mobile: Address: Contact Tel: Relationship (if any) Date of Birth: Is the person who cares for you registered with Rosebank Health? Are you registered disabled? Signed: Yes No Date: Yes No Agreement by Patient to allow Carer access to their personal details and / or copies of correspondence 1 I give permission for my Carer to have access to my personal details and medical records held by Rosebank Health Yes No 1a This Permission relates to all of my Records: Yes No 1b 1c This permission relates to a specific condition: Specify the condition: This permission relates to part of my records: Please specify the parts of the record to which access is allowed and any areas specifically excluded: Yes No Yes No 2 3 I consent to my Carer receiving copies of all correspondence relating to my treatment I confirm that my GP has sole discretion to withhold any or all information from my carer I understand that this permission will remain in force until cancelled by 4 me in writing and that the doctor may override this authority at any time Signed by Patient: Date: Accepted by Doctor: Date: Yes No Yes No Yes No Page 8 of 9
Page 9 of 9