Registration Form Dear Patient Welcome to Picton Medical Centre. In addition to the GMS1 form we ask that you complete our own new patient registration form. This will enable us to provide the best care for you. All information will be held in the strictest confidence. Name NHS NumberIf you know your NHS Number, please complete this box. You can get this information from your previously registered practice Date of Birth Day Month Year Address Street Address Address Line 2 City County / State / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Home Telephone NumberHome Telephone Number Including STD Code (no spaces)Mobile Telephone NumberMobile Telephone NumberPreferred Contact Telephone NumberIf you prefer to be contacted on a different number than above, perhaps another family member or carer, please provide this numberAll patients will be registered for SMS text message reminders if a mobile number is provided. If you DO NOT WANT to receive SMS reminders please tick this box Email Are you a new Patient in the UK? Day Month Year If you are a new patient in the UK, please provide the date that you arrived in the UK.What is your Ethnicity? What language do you speak? Will you need a translator? Yes No Are you registered disabled? Yes No Details Are you a carer? Yes No Details Do you have a carer? Yes No Details Accessible Information Standard: Do you have a disability or sensory loss where further support is needing with communication and information provided? Yes No If yes please select Braille Easy Read Audio British Sign language Other Please state Immunisation History for anyone aged 18 or below. We need your record of immunisation (i.e. red book or equivalent), even if administered in another country. If these can be translated into English it would be very helpful. Are you on any current medication? Yes No If yes, please provide details or repeat medication slip from your last practice. Do you have any allergies? Yes No If so, please state and what reaction did you have? Do you smoke? Yes No If yes, how many per day?Are you an ex-smoker? Yes No Do you drink Alcohol? Yes No If yes, how many units do you drink per week?SUMMARY CARE RECORD (SCR) The NHS in England has introduced the Summary Care Record, which will be used in emergency care. The record will only 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 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. If you would like a Summary Care Record then you do not need to do anything and a Summary Care Record will be created for you. If you do not want a Summary Care Record then sign the opt out below. I do NOT want a Summary Care Record ETP services. Would you like to register for Electronic Prescription Service? Your prescriptions can be sent to a pharmacy of your choice electronically saving you time to collect it from your GP. Yes No If yes, which pharmacy? Practice Policy for On-line Access Before you begin to use the online booking service, please read the following policy and attached agreement. Please keep this policy for your own reference. A document or secure message containing your pin number and log-on details will be provided to you as soon as the Practice receives your signed consent form and documentation to verify your identity. Please keep this document safe as it contains your personal information. When registered you will be able to: View your on line medical records Book doctor or advanced practitioner appointments View appointments you have already booked Cancel appointments Order repeat medication View Test results Submit Questions Access health related information via evergreen Appointments Please ensure that you book any appointments appropriately. If you are unsure as to whether it is appropriate for you to see a doctor or an advanced practitioner, contact us by telephone. Whilst we will do what we can for you to see the clinician of your choice the wait may be longer. Missed Appointments If you are unable to attend your appointment you should cancel it as early as possible. Ways of cancelling: If you are signed up to MJOG, text “cancel” in reply to the text message reminder. Cancel on line. If you cannot cancel by either of the ways listed above you can ring the surgery and we can do this for you. Please remember our phones lines are busy, so give yourself enough time to cancel the appointment so we can give it to another patient. We monitor missed appointments on a daily basis. If you miss an appointment twice times in a six month period will remove the facility for you to use online booking. If you miss 3 appointments in a 12 months period and you may be removed from the practice list. Inappropriate use We are sure you will find this service useful. However, we will revoke your access to it if you abuse the service. For your access to be reinstated you would need to speak to a member of the management team. Examples of what we would consider inappropriate use are: Booking appointments and not using them more than twice a year, Consistently booking inappropriate appointments with the practice for example for self-limiting minor ailments where we have recommended you seek advice from a pharmacist Appointments for Family Members: Unfortunately the system is not flexible enough to allow you to book appointments for family members. Online booking is only available to patients aged 15 and over. Parents can have proxy access to children’s records until the child turns 15. On the child’s 15th birthday online access is automatically turned off. The child can then give proxy access if they are assessed to be competent. Important Information – Please read before returning this form You can use the internet to book appointments, request repeat prescriptions for any medications you take regularly and look at your medical record online. If you do not have on line access you can also still use the telephone or call into the surgery for any of these services as well. It’s your choice. It will be your responsibility to keep your login details and password safe and secure. If you know or suspect that your record has been accessed by someone that you have not agreed should see it, then you should change your password immediately. DO NOT GIVE YOUR USER NAME AND PASSWORD TO YOUR NOMINATED PHARMACY TO ORDER YOUR RPESCRIPTIONS, THEY CAN SEE YOUR CONFIDENTIAL HEALTH RECORD Appointments for Family Members: Unfortunately the system is not flexible enough to allow you to book appointments for family members. Under 16’s: Online booking is only available to patients aged 16 and over If you can’t do this for some reason, we recommend that you contact the practice so that they can remove online access until you are able to reset your password. If you print out any information from your record, it is also your responsibility to keep this secure. If you are at all worried about keeping printed copies safe, we recommend that you do not make copies at all. Before you apply for online access to your record, there are some other things to consider. Although the chances of any of these things happening are very small, you will be asked that you have read and understood the following before you are given login details. Forgotten history There may be something you have forgotten about in your record that you might find upsetting. Abnormal results or bad news If you have asked to be able to view test results or letters, you may see something that you find upsetting to you. This may occur before you have spoken to your doctor or while the surgery is closed and you cannot contact them. Choosing to share your information with someone It’s up to you whether or not you share your information with others – perhaps family members or carers. It’s your choice, but also your responsibility to keep the information safe and secure. Coercion If you think you may be pressured into revealing details from your patient record to someone else against your will, it is best that you do not register for access at this time. Misunderstood information Your medical record is designed to be used by clinical professionals to ensure that you receive the best possible care. Some of the information within your medical record may be highly technical, written by specialists and not easily understood. If you require further clarification, please contact the surgery for a clearer explanation. Information about someone else If you spot something in the record that is not about you or notice any other errors, please log out of the system immediately and contact the practice as soon as possible. Application for Online Access to my Medical Record. I wish to access my medical record online and understand and agree with each statement (please tick all boxes) 1. I have read and understood the information on this form 2. I will be responsible for the security of the information that I see or download 3. If I choose to share my information with anyone else, this is at my own risk 4. I will contact the practice as soon as possible if I suspect that my account has been accessed by someone without my agreement 5. If I see information in my record that it not about me, or is inaccurate I will log out immediately and contact the practice as soon as possible 6. I have understood and will adhere to the practice policy for the use of on-line booking. I will ensure the safe keeping of my user name and password. I understand that failure on my part to adhere to the policy may result in my on-line booking registration being terminated. I understand that this will in no way affect my registration with the practice. Name Date of Birth Day Month Year Date MM slash DD slash YYYY Once you have been registered as a new patient, you will receive a SMS to confirm your registration. Thank you.