Family doctor services registration GMS1

Patient’s details Please complete in BLOCK CAPITALS and tick as appropriate

Surname

Date of birth First names

NHS Previous surname/sNo.

Male Female Town and country

of birth

Home address

Postcode Telephone number

Please help us trace your previous medical records by providing the following informationYour previous address in UK Name of previous GP practice while at that address

Address of previous GP practice

If you are from abroadYour first UK address where registered with a GP

If previously resident in UK, Date you first camedate of leaving to live in UK

Were you ever registered with an Armed Forces GPPlease indicate if you have served in the UK Armed Forces and/or been registered with a Ministry of Defence GP in the UK or overseas: Regular Reservist Veteran Family Member (Spouse, Civil Partner, Service Child)

Address before enlisting:

Postcode

Service or Personnel number: Enlistment date: DD MM YY Discharge date: DD MM YY (if applicable)

Footnote: 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.

If you need your doctor to dispense medicines and appliances*

I live more than 1.6km in a straight line from the nearest chemist

I would have serious difficulty in getting them from a chemist

Signature of Patient Signature on behalf of patient

Date________/_________/_________

Mr Mrs Miss Ms

052019_006 Product Code: GMS1

* Not all doctors are authorised to dispense medicines

NHS Organ Donor registrationI want to register my details on the NHS Organ Donor Register as someone whose organs/tissue may be used for transplantation after my death. Please tick the boxes that apply.

Any of my organs and tissue or

Kidneys Heart Liver Corneas Lungs Pancreas

Signature confirming my consent to join the NHS Organ Donor Register Date ________/________/________

Please tell your family you want to be an organ donor. If you do not want to be an organ donor, please visit www.organdonation.nhs.uk or call 0300 123 23 23 to register your decision.

NHS Blood Donor registrationI 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 my consent to join the NHS Blood Donor Register Date ________/________/________

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

Postcode:All blood types are needed, especially O negative and B negative. Visit www.blood.co.uk or call 0300 123 23 23.

NHS England use only Patient registered for GMS Dispensing

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Family doctor services registration GMS1

To be completed by the GP PracticePractice Name Practice Code

I have accepted this patient for general medical services on behalf of the practice

I will dispense medicines/appliances to this patient subject to NHS England approval.

I declare to the best of my belief this information is correct

Authorised Signature

Name Date _______/_______/_______

Practice Stamp

SUPPLEMENTARY QUESTIONS QUESTIONS - These questions and the patient declaration are optional and youranswers 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 UKAnybody 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.

Please tick one of the following boxes:

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

b) 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

c) I do not know my chargeable status

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.

A parent/guardian should complete the form on behalf of a child under 16.

Signed: Date: DD MM YY

Print name: Relationship to patient:On behalf of:

Complete this section if you live in another EEA 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

Do you have a non-UK EHIC or PRC? YES: NO: If yes, please enter details from your EHIC or PRC below:

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, includingat a hospital.

Country Code:

3: Name

4: Given Names

5: Date of Birth DD MM YYYY

6: Personal Identification Number

7: Identification number of the institution

8: Identification number of the card

9: Expiry Date DD MM YYYY

PRC validity period (a) From: DD MM YYYY (b) To: DD MM YYYY

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). Please give your S1 form to the 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.

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1

New Patient Questionnaire, Westbank Practice

Please complete ALL pages Proof of ID Presented When you register with the Westbank Practice you will need to provide two forms of ID from the list below – please tick next to the documents you have provided:

Birth certificate Bank/building society card/statement Marriage certificate National Insurance number card Medical Card Payslip Driving Licence Letter from Benefits Agency/benefit book/signing on card Passport Papers from the Home Office Local authority rent card P45 Paid utility bills (It is preferable that one item of photo ID is provided, along with one document containing your address)

Are you filling this form out on behalf of someone else: Yes / No

If yes please state your name and relationship to patient:

Patient details

Full Name: DOB:

Marital Status: Married / Widowed / Single / Partnered

Telephone Numbers Home:

*Mobile: Work:

Which is your preferred contact phone number? Home: Work: Mobile:

e-mail address:

If you would like to sign up to SystmOnline please tick here (see page 7 for more info)

*If you provide us with a mobile number we will use text (as appropriate) to contact you unless you tell us otherwise. If you would like to receive SMS messages regarding a child under 11, please fill in your mobile number. Tick here if you DO NOT wish to be contacted via text

Next of Kin

Name:

Phone number & address

Relationship to you:

If you have children, please provide their name(s) and date(s) of birth

Are you a Carer?

Yes/No - If yes who for?

Do you have a Carer? Yes/No

Present occupation

Family medical history

Relatives Significant illnesses Or If deceased, age & cause of death

Father

Mother

Sisters

Brothers

For office use only

New pt appt reqd with Nurse or Dr:

Yes/No

Letter sent:

Prioritise notes (tick if yes)

2

Past medical history, please tick if you have ever suffered from: Asthma Diabetes High Blood pressure Mental illness Angina Heart Attack Stroke Epilepsy Thyroid disease Cancer List previous illnesses and operations including dates. Indicate any from which you still suffer or receive treatment

Smoking Do you currently or have you ever smoked?

Yes - current smoker No - never smoked Ex-smoker date stopped: __________

If current smoker, amount per day

Cigs_________

Cigars__________

Pipe__________

Height and Weight

Height in CM: Weight in KG:

Alcohol Consumption

As a rough guide, 2 units of alcohol = a pint of beer OR a medium glass of wine OR a double shot of spirits Men and women should not drink more than 14 units of alcohol a week.

Questions Please Circle How often do you have a drink that

contains alcohol? Never

Monthly or

less

2 – 4 times per

month

2 – 3 times per

week 4+ times per 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

standard drinks on one occasion? Never Less than

monthly Monthly Weekly

Daily or almost

daily

How often during the past year have you found that you were unable to stop drinking once you had started?

Never

Less than monthly

Monthly Weekly Daily or almost

daily

How often in the past year have you failed to do what was normally expected of you because of alcohol?

Never

Less than monthly

Monthly Weekly Daily or almost

daily

Has a relative/friend or doctor or other Healthcare Professional been concerned about your drinking or suggested you cut down?

No Yes but not in the past

year

Yes, during the past year

Weekly Daily or almost

daily

3

Women Only If you use any form of contraception please indicate which one:

Coil Implant Oral Pill Other:

Number of Pregnancies:

Date of last cervical smear:

Date of last mammogram: Have you ever had a blood transfusion? Yes/No

Immunisations – please indicate those which you have had Childhood: Tetanus

MMR

Hib

TB/BCG

Polio

Whooping cough

Diphtheria Pneumococcal

Adult: Tetanus Pneumococcal Other - e.g. Hepatitis A, B, Rabies etc.

Do you have any allergies? Yes/No If yes please provide details:

Do you have any special needs that will require assistance at the surgery?

Yes/No If you have any particular communication needs please complete the attached form.

Medication – please list CURRENT medication

Forwarding Prescriptions Please select from the list below where you would like us to send your prescription

Starcross Boots

Exminster Pharmacy

Dawlish Warren Pharmacy

Boots in Dawlish

Collect from the Surgery

Other (Please specify)……………………………………………………………………….

If no preference given, prescriptions will be held at the surgery for collection. Please allow 3 working days for us to send prescriptions to a pharmacy

PATIENTS AGED 65 AND OVER

Have you had a flu vaccination this year? Yes No

If No, would you like one this year? Yes No

Have you ever served in the armed forces? (Code as Ua0T3)

YES / NO

If YES are you still a reservist? (Code as Xabnw)

YES / NO

Service or Personnel Number:

Enlistment date:

Leaving Date:

4

ETHNIC ORIGIN QUESTIONNAIRE

This questionnaire follows the recommendations of the Commission for Racial Equality and complies with the Race Relations Act. Please indicate your ethnic origin. This is not compulsory, but may help with your healthcare, as some health problems are more common in specific communities, and knowing your origins may help with the early identification of some of these conditions. Choose ONE section from A to E, and then tick ONE box to indicate your background. Name ...................................................................................... Date of Birth .......................................... A White

B Mixed

C Asian or Asian British

D Black or Black British

E Chinese or other ethnic group

F I decline to give this information □

Please identify your First Language spoken: □ English □ French □ Spanish □ Italian □ German □ Dutch □ Polish □ Other – please state …………………………………………………………………………………………………………………………………………………….

British

Irish

Any other white background please write in below:

White and Black Caribbean

White and Black African

White and Asian

Any other mixed background please write below:

Indian

Pakistani

Bangladeshi

Any other Asian background please write below:

Caribbean

African

Any other Black background please write below:

Chinese

Any other background please write below:

5

SHARING YOUR NHS PATIENT DATA

Information sharing in the NHS is subject to rigorous regulation and governance to ensure your full identifiable and

personal medical data is kept confidential and only ever seen by carefully vetted doctors, nurses and administrative

staff responsible for overseeing your care.

With the development of information technology the NHS will increasingly be sharing key information from your GP

medical notes with Out of Hours GP Services, Hospital A&E Units, Community Hospitals, Community Nurses all of

whom may at various times in your life be looking after you. Sharing information can improve both the quality and

safety of care you receive and in some cases can be vital in making life-saving decisions about your treatment.

There are two different elements aimed at ensuring continuity and safety in your personal care:

SCR = The NHS Summary Care Record

EDSM = The Enhanced Data Sharing Model ‘SystmOne’

We ask you please to read the information on this page carefully and complete the relevant fields on the form overleaf,

sign and return to us.

SCR = NHS SUMMARY CARE RECORD

The NHS Summary Care Record was introduced many years ago to help deliver better and safer

care; it contains basic information about:

Any allergies you may have

Unexpected reactions to medications, and

Any prescriptions you have recently received.

The intention of the SCR is to help clinicians in Hospital A&E Departments and GP ‘Out of Hours’ health services to give

you safe, timely and effective treatment. Clinicians are only allowed to access your SCR record if they are authorised to

do so and, even then, only if you give your express permission. You will be asked if healthcare staff can look at your

Summary Care Record every time they need to, unless it is an emergency, for instance if you are unconscious. You can

refuse if you think access is unnecessary.

Patients under 16 years have an NHS Summary Care Record created for them so if you are the parent or guardian of a

child then please either make this information available to them or decide and act on their behalf.

EDSM = ENHANCED DATA SHARING MODEL – SYSTMONE

The Westbank Practice uses a computer system called SystmOne that gives your GP the facility to share your full electronic records across different NHS Care Services that are involved in your care. Allowing your GP to share your record in the SystmOne database helps to deliver better and safer care for you. You can choose to share or not to share your electronic GP record with other NHS Care Services. If you chose to decline sharing you are able to determine if data is ‘shared out’ and/or ‘shared in’

Sharing OUT controls whether information recorded at our GP practice can be shared with other NHS health care providers.

Sharing IN determines whether or not our GP practice can view information in your record that has been entered by other NHS services who are providing care for you or who may provide care for you in the future (that you have consented to share out).

Please complete and sign the form overleaf to detail your personal decisions regarding NHS patient data sharing.

6

NHS PATIENT INFORMATION SHARING – MY CHOICES

Please complete and/or tick the blue boxes below to detail your personal decisions:

It is very important you sign this form to say that you understand and accept the risks to your personal health

care if you do decide to opt out of SCR or EDSM. Hand the completed form in to your GP Surgery; they will

scan this form into your NHS GP Medical Records and enter the appropriate computer codes.

1. SCR - NHS SUMMARY CARE RECORD

Please tick only one box.

Express consent for medication, allergies and adverse reactions only

Express consent for medication, allergies, adverse reactions and additional information

Express dissent – Patient does not want a summary care record and fully understands the risks involved with this decision

If you do not return this form, a Summary Care Record will be created for you based on implied consent.

2. EDSM – ENHANCED DATA SHARING MODEL - SystmOne

Sharing Out – Do you consent to the sharing of data recorded by your GP practice with other NHS

organisations that may care for you?

YES share data with other NHS organisations

NO do NOT share any data recorded by my GP Practice; I fully accept the risks associated with this

decision

Sharing In – Do you consent to your GP Practice viewing data that is recorded at other NHS organisations and

care services that may care for you?

Consent Given

Consent Refused; I fully accept the risks associated with this decision.

Patient’s SIGNATURE

DATE

If you are filling out this form on behalf of another person or a child please ensure you fill out their details above and your details here:

Your Name Your signature

Relationship to Patient Date

7

Online Services SystmOnline allows you to book appointments online, request repeat medications and view your medical history and test results. You can also update your address and contact information, and it allows you to answer review questionnaires (currently we are trialling this for some asthma patients and hope to extend this to other medical conditions). You can download the SystmOnline app on your smartphone or tablet, or you can access the website via your laptop or desktop. To use SystmOnline, please supply a mobile number and/or email address on page one of this form and tick the box to consent to signing up. We will then send you your log in information to either you mobile number or email address. Once you have registered for SystmOnline, you can then request access to your detailed coded record where you can view your test results amongst other bits of information. Detailed coded record access needs to be approved by your GP so this will not be accessible straight away. If you are a carer or have a child under the age of 11 and require proxy access, please contact reception for a sign up form with a piece of photo ID (like a driver’s license or passport).

The NHS App also allows you to book appointments online, request repeat medications, view your medical history and test results, as well as links to NHS 111 help pages to check symptoms. You can even change your organ donor registration decisions. You can currently only sign up to this via a smartphone or tablet through an app (there is no desktop site just yet). The sign up process is simple; you put in your details, and record a short, four second long video for verification. To download the app search for ‘NHS App’ on the App Store or Google Play and register from home.

eConsult allows you to start an online consultation with your doctor, with a response usually by the end of the next working day. It also points you in the right direction for help and treatment, and can actually help save appointments for people that need them more. To start an eConsult visit our website www.westbankpractice.com. You do not need to register to use this service.

8

Westbank Practice

ACCESSIBLE INFORMATION NEEDS QUESTIONNAIRE

We wish to understand and record any particular communication needs you might have. We will then do our best to meet your needs in all contacts with the Practice. Completed by patient / guardian / carer

1. Is your communication with others affected by a health problem or disability

which has lasted, or is expected to last, at least 12 months?

YES / NO

If YES please complete the rest of the questionnaire

If NO you don’t need to answer any other questions

2. What health problem or disability do you have?

3. What is the best way for us to send you information?

4. Do you need written information in a format other than standard print?

5. What communication support could we provide for you at appointments?

6. Can we share this information with other health and social care providers?

YES / NO