BRIDGE MEDICAL CENTRE NEW PATIENT REGISTRATION FORM-ADULT

BRIDGE MEDICAL CENTRE NEW PATIENT REGISTRATION FORM-ADULT We only accept patients within our catchment area of Three Bridges, Pound Hill, Worth, Maidenbower, Furnace Green, Tilgate, Northgate, Copthorne & Forge Wood. If you move from these areas, you may be asked to register elsewhere. Title: Mr / Mrs / Miss / Ms / Dr / Prof / Rev / Other Surname: First name: Previous surname: Date of Birth: Address & Postcode: Telephone: Home: Work: Mobile: email: Gender: Male / Female Marital Status: NHS number: single / married / living with partner / civil partnership / divorced / widowed Town and country of birth: Occupation: Please give names of any children living with you: Please help us trace your previous medical records by providing the following information: Previous Address in the UK Previous GP & Address: If you are from abroad: Your first UK address where registered with a GP: If previously resident in the UK Date of leaving: Date you first came to live in the UK: If you are returning from the armed forces: Address before enlisting: Service/Personnel number: Enlistment How did you find us? Please circle your answer NHS choices website/ online search engine / word of mouth / saw practice when passing Other

Due to government policy, we are obliged to ask you the following: Please state your first spoken language English language spoken? YES / NO If not, will you ever require the interpreter service at the surgery? What is your Nationality? What is your ethnic group? (Please only choose ONE and tick the appropriate box) White, Black or Black British, Eastern Asian British Caribbean Chinese European African Vietnamese Mixed Asian or Asian British, Middle Eastern White & Black Caribbean Indian Arabic White & Black African Pakistani Iranian White & Asian Bangladeshi Turkish Any other group not stated above I do not wish to state my ethnic group Do you consider yourself to have a disability or any sensory loss? Yes/No/I prefer not to answer this question If so, please state: Are you an asylum seeker? If so, from which country? In the future we would like to be able to send appointment and other reminders and letters via TEXT and/or EMAIL. Do we have your permission to send texts and emails? I consent to receiving TEXTS I consent to receiving EMAILS If we are trying to contact you and we get an answerphone are you happy for us to leave a message? I consent to answerphone messages on my home phone (please tick as appropriate) I consent to answerphone messages on my mobile phone Online Access to Medical Records, Appointments and Repeat Medication We offer online access to patients aged 16 or over to view a summary of their medical record, prescription ordering and online appointments. If you would like to sign up for this please read the attached document Getting Started with Online Services and complete appendices A and B. It would greatly assist us if you could bring photographic ID (passport or driving licence and a recent utility bill as proof of your address) when you register. This will also be needed to confirm your identity if you require online access Personal Medical History Please specify any major illnesses, operations or disabilities, with dates:

Alcohol Consumption 1 unit = ½ pint beer; small glass wine or 1 measure of spirits Questions Score 0 Score 1 Score 2 Score 3 Score 4 Your score How often do you have a drink Monthly or 2-4 times 2-3 times 4+ times per Never that contains alcohol? less per month per week week How many standard alcoholic drinks do you have on a typical day when you are drinking? 1-2 3-4 5-6 7-8 10+ How often do you have 6 or more Less than Daily or standard drinks Never Monthly Weekly monthly almost daily on one occasion? Height: Smoking status: Weight: Never smoked / ex-smoker / smoker (please circle) IF YOU SMOKE, WE WOULD ENCOURAGE YOU TO STOP AS SMOKING WILL DAMAGE YOUR HEALTH. Please ask your GP or Nurse for help and advice. Medication If you are on regular medication you will need to make an appointment to be reviewed as soon as possible, please advise the receptionist and she will arrange an appointment for you. Please list all current medication: Do you have any allergies? Yes/No (Please state) Do you have a carer? Yes/ No If so, please let us know the name of your carer and relationship to you: If you would be happy for the practice to discuss your medical care on your behalf, please complete the form at the back of this pack- consent to discuss medical records Are you a carer? If so, please let us know the name of the person you care for and their relationship to you: We have a Carer Support Worker- please let us know if you would like to be referred.

Our practice has a full range of services which will be available to you when needed. Please let us know if you need to be referred to any of the following: Midwives, Health Visitors, Community Psychiatric Nurses, Associated Counsellors such as Time to Talk and Weight Off Programs (eg WOW). Prescriptions are now sent to chemists via the Electronic Prescribing Service (EPS). This is an NHS service that enables doctors to send your prescription directly to your chosen chemist. Please ask if you would like further information about this service. An information sheet and pharmacy nomination form is attached. PLEASE ADVISE WHICH CHEMIST YOU WOULD LIKE YOUR REPEAT PRESCRIPTION TO BE SENT: (Please tick the appropriate box) Boots County Mall Boots Maidenbower Asda Tesco (Hazelwick) Kamsons Pound Hill Lloyds Tilgate Sainsbury s Geddes Kassams, Three Bridges Williams, Furnace Green Rivermead, Copthorne Jades, Northgate other Did you know we have a Patient Participation Group? FRIENDS OF BRIDGE MEDICAL CENTRE The group is divided into two sub-groups. One group is our real time group that meet every couple of months for about an hour here at the surgery, usually during the lunch time period. Our other group is the virtual group who correspond via email. We believe that working and listening to our patients will help us understand our patients needs and enable us to provide the services our patients want. If you would like further information on the real time group, please write to Mrs Sharon Harrison our Practice Manager who will contact you and put you in touch with the group chairman. Are you are interested in participating in our virtual group? Please circle: YES / NO If YES, please provide your email address: We look forward to hearing your views. (edsm) SHARING OF YOUR MEDICAL RECORDS BETWEEN HEALTH PROFESSIONALS. In order to provide the best and safest health care it is possible to allow clinicians caring for you to view medical information recorded by other healthcare services. For example it may be useful for your GP to be able to read information recorded by a district nurse to monitor your care and make a more informed decision when planning how best to treat you. Can I refuse to share? Yes, you have the right to choose which services can share information or view shared information and you can change your mind at any time. PLEASE TICK TO REFUSE TO SHARE If I agree to share, who can view my information? Only health professionals who are currently involved in your healthcare and you have given consent to view can see information in the shared record. PLEASE TICK TO AGREE TO SHARE Can I hide specific entries on my record while sharing the rest of my information? Yes. If there is some information you do not wish to be shared, ask your health professional not to share that information.

(SCR) SUMMARY CARE RECORD your emergency care summary Your Summary Care Record will be available to authorized 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, healthcare staff treating you will have immediate access to important information about your health. As a patient you have a choice, please tick one of the following:- 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 please complete the attached opt-out form and hand it back to a receptionist Please ask at reception for more information regarding Record Sharing or Summary Care Records NHS ZERO TOLERANCE TO VIOLENT AND ABUSIVE BEHAVIOUR I fully understand that the NHS is operating a permanent zero tolerance policy towards violent and abusive behaviour. This includes harassment, alarming, distressing, threatening, abusive, and insulting as well as violent behaviour by an individual. This policy applies to all Health Service facilities including all areas of general practice and primary care. I further understand that should I be party to violent, threatening or abusive behaviour towards any member of the Bridge Medical Centre team, then I will expect that certain sanctions will be applied to me. This could include removal from the practice registration list and could mean I will have to be seen at an approved secure centre for violent patients. I am aware that difficulties may occur in the provision of my medical care and that cannot be the responsibility of any one Health Care Professional. I am also aware that violent, threatening or abusive behaviour cannot alter the situation, which is often beyond the individual Health Care Professional s control. I agree that on becoming a registered patient at Bridge Medical Centre, I will not use any form of violent, threatening or abusive behaviour towards any member of staff at any time. Please sign to confirm the information you have provided is accurate to the best of your knowledge and that you have read all the information (including the zero tolerance statement) contained in this document. Patient signature: Print Name:

[For office use only] Are they living in our catchment area? Is form fully completed? (please ask patient to complete anything that is missing) Has the patient signed, printed their name and dated the form? Passport or photo ID seen? Passport Number: Expiry date: Bus pass number/driving Licence Number: Expiry date: If applicable is there a valid visa? (if in doubt please check before accepting paperwork) Have you seen proof of address (utility bill from last 3 months)? Have they completed consent to discuss medical records if they have a carer? If they want online access, please ensure ID is verified and the forms are completed. Including the information sheet Getting Started with GP Online Services which is separate. Have they selected a chemist for electronic prescribing? Please give them an EPS Nomination Information sheet and form if required. /NA / NA /not required / declined Form checked by: Signature: Print name: Registration completed (entered on TPP) by: Data Entry completed (entered on TPP) by: (smoking/alcohol/height/weight) Signature: Print Name: Signature: Print Name:

Patient Consent Form for Detailed Coded Record Access Appendix A You can now view your GP medical record online to look at test results, details of consultations and your medical history, including current and past medication. 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 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. Access is granted at the discretion of the practice. Your request for access may take up to 7 working days to process. You will be informed if access cannot be granted. Declaration (please delete response as appropriate): 1. I agree to my GP practice giving me access to my record online and confirm that I YES / NO have not been coerced/forced into asking for access 2. I have been provided with information leaflet called Getting started with GP Online YES / NO Services about access to GP medical records which I have read and understood. 3. I agree to use the system in a responsible manner in accordance with all instructions YES / NO 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 YES / NO the matter to the practice as soon as possible. 5. I agree that it is my responsibility to keep secure my username and passwords. If I YES / NO 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 YES / NO service and whether it could be improved. 7. I understand that online access is granted at the discretion of the practice, taking into YES / NO 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. 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 the practice manager as soon as possible of any errors or omissions. 9. I understand that I may see information on my record and abnormal results that I was unaware of / have forgotten about that could cause distress.eg History of adoption, abuse, old diagnoses or operations. 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 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. Patient Details Surname Date of Birth First Name(s) NHS number (if known) Email* YES/NO YES / NO YES / NO *If this address is shared with others please consider whether you agree that it can be used to send you confidential information about your account / the services used. Do you currently already have Patient Access Online Services? YES / NO To be signed at reception by patient..... Date

APPENDIX Appendix B C Patient Name: Three Bridges Crawley West Sussex RH10 1LL Telephone 01293 526025 Facsimile 01293 553490 Website www.bridgemedicalcentre.co.uk BRIDGE MEDICAL CENTRE Website www.nhs.uk It is now possible to use the internet to book some appointments, request repeat prescriptions for medications you take regularly and a detailed summary of your record. If you are aged 16 or over and would like access to this facility, please complete this form and hand it in at reception. We will need to verify your identity for data protection so please bring photographic ID and separate proof of your address (e.g. a utility bill or bank statement dated within the last 3 months a driving licence is not acceptable as proof of your address). An account will be created for you and you will be advised when the details will be ready for you. You will need ID with you when collecting the letter. Patient NHS Number: Address: DoB: Patient email: Patient Mobile: Preferred Method of Contact for online services messages : Mobile Email I consent to email and SMS text communications I request online access for: (please tick all that you would like access to) Online appointments Ordering medication Medical Record Summary Detailed Coded Medical Record I will be responsible for the security of the information I see or download If I choose to share information, this is at my own risk I will contact the practice as soon as possible if I suspect my account has been accessed by someone without my agreement If I see information in my record that is not about me or inaccurate I will log out and contact the practice. I confirm that I have read the information above and agree with all statements Patient signature: OFFICE USE ONLY: Identity verified by: Signed: Print name: Method: (Passport/driving licence & utility bill) Photo ID & proof of address PLEASE CONFIRM PATIENT IS 16 OR OVER Date Account Created: Access granted: Repeat prescriptions Appointments Summary record Detailed Record Date verified: Verification not needed. Already has access to online services: CONFIRM AGE: Signed:

CONSENT TO DISCUSS MEDICAL RECORDS IF YOU WANT ANY OTHER PERSON TO BE ABLE TO DISCUSS YOUR MEDICAL RECORDS, RESULTS OR APPOINTMENTS, PLEASE COMPLETE THIS FORM. I (patient name) give consent for the Doctors and staff at Bridge Medical Centre to discuss my medical records with: Name... Relationship (Insert above, the name of the person to be given permission and their relationship to you) Signed.. Print Name Date of Birth Today s date.