New Patient Registration - Southway Surgery

If you would like to register with the practice please use this form.

To register a new patient you will need to live within our practice boundary.

It is very easy to register at the practice. You do not need a medical card. We ask you to sign the registration form at reception and then complete a short health questionnaire. Your notes will be transferred from your last doctor, but this can take up to 2 months.

For children less than 5 years of age please indicate on the registration form if you require your child to receive Child Health Surveillance from the practice.

We request that you attach ID, if possible, before submitting this form.

Step 1 of 2

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Name

Prefix First Last

Prev Surname: Optional

NHS Number:

Date of Birth

Day

Month

Year

Sex:

Male

Female

Ethnicity:

First Spoken Language:

Town and Country of Birth:

Address

Street Address Address Line 2 City Postcode

Contact Number

Email Address

Enter Email Confirm Email

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

Previous Address

Street Address Address Line 2 City Postcode

Name of Doctor while at that address

Address of previous doctor

Street Address Address Line 2 City Postcode

Are you from abroad?

Yes

Are you in the Armed Forces?

Yes

If you are from abroad:

Your first address where registered with a GP

Street Address Address Line 2 City Postcode

If previously resident in UK, date of leaving

DD slash MM slash YYYY

Date you first came to live in the UK

DD slash MM slash YYYY

If you are from the Armed Forces:

Address before enlisting

Street Address Address Line 2 City Postcode

Service or Personnel number

Enlistment date

DD slash MM slash YYYY

Discharge date Optional

DD slash MM slash YYYY

If registering a child under 5:

I wish the child above to be registered with the doctor named overleaf for Child Health Surveillance. Optional

If you need your doctor to dispense medicines and appliances:

Not all doctors are authorised to dispense medicines.

I live more than 1 mile in a straight line from the nearest chemist. Optional

I would have serious difficulty in getting them from the chemist. Optional

NHS Organ Donor registration:

Please tick as appropriate:

Any part of my body Optional

Or only my:

Kidneys Optional

Heart Optional

Liver Optional

Corneas Optional

Lungs Optional

Pancreas Optional

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. Optional

Tick here if you have given blood in the last 3 years. Optional

Emergency Contact

Name:

Relationship: Optional

Contact Number:

Address

Street Address Address Line 2 City Post Code

I have filled in this form on behalf of

NEW PATIENT QUESTIONNAIRE

Please answer these questions to the best of your ability and hand this questionnaire into the receptionist. The information will be used to update your personal medical record.

Name

Date Of Birth

Day

Month

Year

Phone Number

Email Address

Height

Weight

What is your smoking status?

How many cigarettes do you smoke a day?

When did you stop smoking?

DD slash MM slash YYYY

Do you drink Alcohol?

How many units a week do you drink?

How often do you have a drink containing Alcohol?

How many units do you drink on a typical day?

How often in the last year have you had 6 or more units (Female) or 8 or more units (Male) on a single occasion?

Do you have any allergies?

Which Drugs/Medication? Optional

What are your allergies?

Are you on any regular medication?

What medication?

Have you recently come to the U.K. from a country which has a high incidence of tuberculosis e.g. Lithuania or Romania?

If you have had a cough or any unexplained weight loss recently please make an appointment to see one of the doctors.

From which Country? Optional

Are you a student?

Have you had your MeningitusACWY vaccination?

Sharing your Health Record

What is your health record?

Your health record contains all the clinical information about the care you receive. When you need medical assistance, it is essential that clinicians can securely access your health record. This allows them to have the necessary information about your medical background to help them identify the best way to help you. This information may include your medical history, medications, and allergies.

Why is sharing important?

Health records about you can be held in various places, including your GP practice and any hospital where you have had treatment. Sharing your health record will ensure you receive the best possible care and treatment wherever you are and whenever you need it. Choosing not to share your health record could have an impact on the future care and treatment you receive. Below are some examples of how sharing your health record can benefit you:

• Sharing your contact details This will ensure you receive any medical appointments without delay

• Sharing your medical history This will ensure emergency services accurately assess you if needed

• Sharing your medication list This will ensure that you receive the most appropriate medication

• Sharing your allergies This will prevent you being given something to which you are allergic

• Sharing your test results This will prevent further unnecessary tests being required

Is my health record secure?

Yes. There are safeguards in place to make sure only organisations you have authorised to view your records can do so. You can also request information regarding who has accessed your information from both within and outside of your surgery.

Can I decide who I share my health record with?

Yes. You decide who has access to your health record. For your health record to be shared between organisations that provide care to you, your consent must be gained.

Can I change my mind?

Yes. You can change your mind at any time about sharing your health record, please just let us know.

Can someone else consent on my behalf?

If you do not have capacity to consent and have a Lasting Power of Attorney, they may consent on your behalf. If you do not have a Lasting Power of Attorney, then a decision in best interests can be made by those caring for you.

What about parental responsibility?

If you have parental responsibility and your child is not able to make an informed decision for themselves, then you can decide about information sharing on behalf of your child. If your child is competent then this must be their decision.

What is your Summary Care Record?

Your Summary Care Record contains basic information including your contact details, NHS number, medications, and allergies. This can be viewed by GP practices, Hospitals, and the Emergency Services. If you do not want a Summary Care Record, please ask your GP practice for the appropriate opt out form. With your consent, additional information can be added to create an Enhanced Summary Care Record. This could include your care plans which will help ensure that you receive the appropriate care in the future.

How is my personal information protected?

Southway Surgery will always protect your personal information. For further information about this, please see our Privacy Notice on our website or please speak to a member of our team.

For further information about your health records, please see: www.nhs.uk/NHSEngland/thenhs/records.

For further information about how the NHS uses your data for research & planning and to opt-out, please see: www.nhs.uk/your-nhs-data-matters/.

Your Health Record

Do you consent to your GP practice sharing your health record with other organisations who care for you?

Yes (recommended option)

Do you consent to your GP practice viewing your health record with other organisations who care for you?

Yes (recommended option)

Your Summary Care Record (SCR)

Do you consent to having an Enhanced Summary Care Record with Additional Information?

Yes (recommended option)

Signature

Signed on behalf of patient Optional

What is your first main spoken language?

Will you need a translator when you see one of our medical team?

Sharing your medical record

An informed patient, in consultation with a Healthcare Professional, can choose to permit or restrict access to the information entered into your record at each organisation that accesses your record. You will be asked to give your record sharing consent at each organisation at which you receive care. Your consent can be changed at any time.

Sharing in

Do you consent to the sharing of data recorded here with any other organisations that may care for you?

Yes – Share data with other organisations

No – do not share any data recorded here

Sharing Out

Do you consent to the viewing of data by this organisation that is recorded at other care services that may care for you and where you have agreed to make the data shareable?

Consent given

Consent refused

Please upload your ID below ( Driving licence / passport / birth certificate) along with proof of address, alternatively please visit the surgery with your ID, we will be unable to register you without it.

File Optional

Drop files here or

Max. file size: 50 MB.

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

If you are from abroad:

If you are from the Armed Forces:

If registering a child under 5:

If you need your doctor to dispense medicines and appliances:

NHS Organ Donor registration:

NHS Blood Donor registration

Emergency Contact

NEW PATIENT QUESTIONNAIRE

Sharing your Health Record

Your Health Record

Your Summary Care Record (SCR)

Sharing your medical record

Sharing in

Sharing Out

THANK YOU FOR TAKING THE TIME TO COMPLETE THIS QUESTIONNAIRE