Welcome to Church Lane Surgery / Dymchurch Surgery This form will help us when you attend your first appointment. Please fill in this form to the best of your ability and return to Reception. First names: Surname: Date of Birth: Male/Female (Please circle) Home No: Mobile: Work No: Next of Kin: Relationship: Email: Number: Discuss Medical Records? Ethnicity Please circle. If you prefer not to say please tick White Mixed Asian or Asian Black or Black Other Ethnic Groups Irish Any other white background White and Black Caribbean Indian Caribbean Chinese White and Black Pakistani African Any other ethnic African group (write) White and Asian Bangladeshi Any other Black background Any other Mixed Any other Asian background background Language What is your first language? Do you speak English? Yes/No (Please circle) Do you need an interpreter? Yes/No (Please circle) Disability Do you consider yourself to have a disability? Yes/No (Please circle) If yes, please state your disability: Family History Please write below any family history of Diabetes, Asthma, Heart Disease etc:... Dr RF Cullen & Partners Page 1 of 5
Medication If you are taking medication regularly you must bring a copy of the B-Side of your prescription or a list from your previous practice with you when you return this form. If you do not, we may not be able to continue prescribing your medication. When you join our practice, the GPs may need to see you to review your medication. If any medications have upset you in the past, please give name of medication and details: Alcohol Screening If you are 16 or over please answer the following questions. Questions How often do you have a drink containing alcohol? How many units of alcohol do you drink on a typical day when you are drinking? Scoring system 0 1 2 3 4 Never Monthly or less 2-4 month 2-3 week 4+ week 1-2 3-4 5-6 7-9 10+ Your score How often have you had 6 or more units if female, or 8 or more if male, on a single occasion in the last year? Never Less than monthly Monthly Weekly Daily or almost daily Height/Weight What is your Height?... What is your Weight?... Smoking Status If you are 16 or over please circle and answer the following questions. Do you do the following? Currently Smoke Used to Smoke Never Smoked Amount day? Allergies Please list any medication, food or animal allergies below Dr RF Cullen & Partners Page 2 of 5
Consent Agreements Leaving Messages In accordance with the Data Protection Act, the Practice needs consent from any patient that has an answerphone and is happy for us to leave a message. If we do not have consent, we will NOT be able to leave a message on an answerphone or with a 3 rd Party. I give consent for the Practice to leave messages on my answerphone. Telephone number... and/or. I do not give consent for the Practice to leave a message on my answerphone. I give consent for the Practice to leave a message about any aspect of my medical treatment with.. This consent is to remain in force until further notice cancellation by me. Email Information Consent Form I would like to receive communications via my email address. I understand you will NOT disclose any confidential information and I am aware that once information leaves the security of your NHS Email Zone, you cannot guarantee or take responsibility for its confidentiality. My Email Address is Date. I agree it will be my responsibility to inform the practice if there are any changes to my email address. SMS Messaging Please tick the following if you would/wouldn t like to receive SMS Messages on my mobile number from the surgery regarding updates and appointments reminders. I give mission for the Practice to send SMS Messages to my mobile number. I do not give the Practice to send SMS Messages to my mobile number. Discussing your Medical Records Do you give mission for us to discuss your past/present medical details with a named representative Yes/No If YES, Please complete the following details: Name of representative: Relationship of representative:. Summary Care Records Please complete the attached opt out form if you wish your clinical information to be withheld from the Summary Care Records. Please sign to confirm that you are happy with the above: Signature Date. Dr RF Cullen & Partners Page 3 of 5
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 mission 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 you can talk to our Patient Advice and Liaison Service (PALS) (0800 085 6606 (Monday to Friday, 9am to 5pm)), visit the website www.easternandcoastalkent.nhs.uk/scr/, 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 Practice Manager Dr RF Cullen & Partners Page 4 of 5
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 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 son or a 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. Your emergency care summary Actioned by practice: yes/no Date... Dr RF Cullen & Partners Page 5 of 5