New Patient Registration Form and New Patient Questionnaire

Last Updated: 31/01/2023

My Details

Title *

Mrs

Miss

Previous surname(s)

Date of Birth *

Occupation *

First name (s) *

Surname *

Patient Registration Form

NHS No.

Gender *

Male

Female

Other

Town and country of birth *

Home address *

Postcode *

Telephone *

Patient Registration Form: Medical Records

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

Your previous address in the UK *

Name of previous GP while at that address

Address of previous GP practice

Patient Registration Form: If you are from abroad

Your first UK address where registered with a GP

If previously a resident in UK, date of leaving

Date you first came to live in UK

Patient Registration Form: Armed Forces

Were you ever registered with an Armed forces GP? Note: 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.

Please 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

Discharge date (if applicable)

Patient Registration Form: If you need your doctor to dispense medicines and appliances*

Not all doctors are authorised to dispense medicines.

Do you...

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

Have serious difficulty in getting them from a chemist

Signature of Patient

Signature on behalf of patient

Date

Patient Registration Form: NHS Organ Donor Registration

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.

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

Any of my organs and tissues

Kidneys

Heart

Liver

Corneas

Lungs

Pancreas

Signature confirming my consent to join the NHS Organ Donor Register

Date

Patient Registration Form: Supplementary Questions Questions

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 Registration Form: 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 to 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:

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

Patient Registration Form: 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 *

On behalf of

Relationship of patient

Patient Registration Form: 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

Country code

Given names

Personal Identification Number

Identification number of the institution

Identification number of the card

Expiry date

PRC validity period (to and from)

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.

Yes No

Patient Registration Form: 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.

Personal Health Questionnaire

Patient Registration Form: NHS Blood Donor Registration

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

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 *

Yes No

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)

Smoking is bad for your health. Our practice strongly recommends that you stop and we have specially trained nurses that can help you do this. Please book an appointment with our nurses who will be able to support you.

Weight (please state if kg, st or lbs) *

Height (please state if cm, ft or inches) *

Alcohol

27% of men and 15% of women in the UK drink excessively, placing themselves at an increased risk of future health or social problems (ONS 1998). The Department of Health guidelines for safe drinking state that: - For men, drinking between 3 and 4 units of alcohol a day or less indicates no significant risk to health. Regularly drinking 4 or more units of alcohol a day indicate an increased risk. - For women, drinking 2 and 3 units a day or less indicates no significant health risk. Regularly drinking 3 or more units a day signifies an increased risk to health. It is recommended that people do not drink up to the recommended limits every day. Approximately 1 unit= 1/2 pint f beer/1 measure of spirit/1 glass of wine. Please book an appointment if you would like help reducing your alcohol consumption.

Next of Kin

Full name *

Telephone Number *

Relationship (ie. mother/father/sister/uncle/Special Guardianship Order) *

Do you have parental responsibility for this child? *

Yes No

Are you a regular blood donor? *

Yes No

What is your current occupation? *

Signed *

Date *

PERSONAL & FAMILY HISTORY DECLARATION

Name *

Date of Birth *

Medication

Are you currently taking any medication? If so, please provide a list of your current medication *

Current Personal History

Past Personal History

Please provide us with any details of any serious illness, injuries or operations you have had in the past including the date/year. *

Family History

Do you have any family history of any of the following?

PREFERRED METHOD OF CONTACT

As of 01 April 2019, we need to know your preferred method of contact. This could be by home telephone, mobile, email or letter and we will do our very best to use this method.

NHS SUMMARY CARE RECORD WITH ADDITIONAL INFORMATION.

If you are registered with a GP practice in England you will have a Summary Care Record (SCR), unless you have previously chosen not to have one. It includes important information about your health: - Medicines you are taking - Allergies you suffer from - Any bad reactions to medicines You may need to be treated by health and care professionals that 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 an SCR means that when you need healthcare you can be helped to recall vital information. SCRs can help the staff involved in your care make better and safer decisions about how best to treat you. You can choose to have additional information included in your SCR, which can enhance the care you receive. This information 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 - Who should be contacted for more information about you What to do next? If you would like this information adding to your SCR, then please complete this form. If you require any more information, please visit https://digital.nhs.uk or phone NHS Digital on 0300 303 5678 or speak to your GP Practice

Name of Patient *

Date of Birth *

Patient's Postcode *

Surgery name *

Surgery Location (Town) *

NHS Number

Signed *

If you are filling out this form on behalf of another person, please ensure that you fill out their details above; you sign the form above and provide the details below.

Name

Capacity

Parent

Legal Guardian

Lasting Power of Attorney

DESIGNATED PHARMACY

We need to know who you wish to collect your prescriptions from. It is entirely your choice who your chosen or designated pharmacist is. Your prescription will automatically be sent to this pharmacist for any repeat medication you receive. If you do not have any medication on repeat, please still advise us of your chosen pharmacy for any prescriptions you may have in the future once registered at this surgery. Please make sure your pharmacist is aware that you have requested them as the designated pharmacist.

Please choose from one of the following *

Haverhill Pharmacy

Tesco Pharmacy

Sainsbury's Pharmacy

Boots

Well (Co-Op)

David Holland

Other (please specify)

Access to Online Services

Would you like to be able to have access to order your repeat medication and book a routine doctor's appointment online? We can offer this service for you, however, you must be over 16 years of age. If you would like to use our online services please complete the form and we can generate a password for you to be able to activate this service. It is completely confidential and you will receive your password either in person or in the *post once you have been registered. *In the event of posting the details to you, we will require one of the forms of ID to be proof of your current address. Once you have received a password, please go to our website www.haverhillfamilypractice.co.uk and click on the link and follow the instructions.

Would you like to have access to online services? *

Yes No

Carers' Register

Haverhill Family Practice is currently updating updating their Carers Register. Are You A Carer? Do you care for someone? Do you care for your mother, father, child or somebody else? Do you have a parent, child or someone else that has a physical or mental illness, long term or life limiting condition and or needs additional support? Do you care for anyone full or part time? If this is the case you are 'caring' for them. Please let us know if you do care for somebody, even a friend or neighbour. We as a surgery can offer you additional support to help with this. In the winter months for instance, you would be entitled to a free flu vaccination. We know how flu can affect those with chest problems, the elderly, the vulnerable, friends or family members and if you protect yourself, you can help to protect those you care for by having an annual flu vaccination, therefore preventing the likelihood of you getting flu, or getting it as severely. This could help to prevent the spread of infection to a child or and adult from getting flu which in some cases can result in a hospital admission. We have Suffolk Family Carers that come to the surgery on a regular basis who offer help, support, kindness and our doctors can offer respite on prescription if required. We have lots of information in our waiting room at both Camps Road and at Crown Passage (Stourview) that can help with any issues, concerns or worries you may currently have. There are leaflets and telephone numbers that may be of use to you. You can contact Suffolk Family Carers directly by telephone on: 01473 835407. Or go to their website www.suffolkfamilycarers.org or email their team at healthteam@suffolkfamilycarers.org. If you think that you might be a 'carer' of someone, please complete the questions below.

Your baby's vaccination schedule

Don't forget to book your 6-8 week baby check (your baby needs to be registered with one of our doctors by this time) and your post-natal examination with the Doctor prior to having your baby vaccinated. Once you have had your post-natal examination and baby check- book your appointment at reception for your baby to have their vaccinations. One of the best ways to protect your baby against diseases like measles, rubella, tetanus and meningitis is through immunisation. Your baby needs their first injections at 8 weeks, then 12 weeks, 16 weeks and one year. Bring your red book to all vaccination appointments. Vaccinations are offered free of charge in the UK- just book your appointments with your GP. Remember, as well as protecting your own baby, you're also protecting other babies and children by preventing the spread of disease. These are the vaccinations your baby will need: 8 weeks: - 6-in-1 vaccine - PCV (pneumococcal) vaccine - RV (rotavirus) vaccine - MenB vaccine 12 weeks: - 6-in-1 vaccine- 2nd dose - RV (rotavirus) vaccine- 2nd dose 16 weeks: - 6-in-1 vaccine- 3rd dose - PCV (pneumococcal) vaccine- 2nd dose - MenB vaccine- 2nd dose 1 year: - Hib/MenC vaccine given as a single jab containing vaccines against meningitis C (1st dose) and Hib (4th dose) - MMR vaccine (measles, mumps and rubella), given as a single jab - PCV (pneumococcal)- 3rd dose - MenB vaccine- 3rd dose

A quick guide to your baby's vaccinations

- 6-in1 protects against: - Diphtheria- a highly contagious bacterial infection, spread by coughs and sneezes, or close contact with someone with diphtheria. - Hepatitis b- an infection of the liver caused by a virus spread through blood and bodily fluids. - Hib (haemophilus influenzae type b)- bacteria that can cause several serious conditions including meningitis, sepsis (a king of blood poisoning) and cellulitis. - Polio- a viral infection that can cause paralysis. - Tetanus- bacteria that can enter the body through a wound like a cut or scrape. - Whooping cough (pertussis)- a highly contagious bacterial infection of the lungs and airways. - PCV or pneumo jab protects against pneumococcal infections that can lead to pneumonia, sepsis and meningitis. - RV protects against rotavirus infection that can cause diarrhoea and vomiting. - MenB protects against meningitis and sepsis - Hib/MenC protects against haemophilus influenzae (a bacterium that can cause different serious illnesses) and meningitis C. - MMR protects against measles, mumps and rubella (German measles).

Please provide TWO forms of ID- one must be photographic (passport/driving license)

Once you have registered, please either drop your two forms of ID into the surgery or send them to us via email (wsccg.hfp-correspondence@nhs.net). Please label your subject as NEW PATIENT PROOF OF IDENTIFICATION. Thank you.

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New Patient Registration Form and New Patient Questionnaire

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