Have you been registered at this practice previously?
Personal Details Name
Dr. Miss Mr. Mrs. Ms. Mx. Prof. Rev.
Title
Forename/s
Surname
Date of Birth Sex Address
Email Are you happy for us to contact you by Text message? Are you happy for us to contact you by Email? Refugee Asylum Seeker Do you require an interpreter when you see a Doctor/Nurse? Next of Kin Name
First
Last
Accessible Information Do you have any disability, impairment or sensory loss? Please add any relevant details Optional
Do you have any special communication needs? Sign Language Are you a Carer? Do you have a Carer?
Medical History Do you suffer or have suffered from any of the following conditions? Have you any other serious illness, operations or accidents? Please list any other serious illness, operations or accidents you have had in the past (give dates when possible).
Are currently taking any medicines/tablets? Please list any Medicines/Tablets you are currently taking:
Do you have any allergies? Please list your allergies
Family Medical History Has a member of your immediate family (Father, Mother, Siblings and Grandparents) had or suffered from any of the following? If ‘yes’, please state relationship and condition.
Have you ever had any of the following immunisations
Female Patients Only Date of last Smear (if applicable) Result of last smear Have you had a full hysterectomy? Date of full hysterectomy Are you using any contraception? Date of last Breast Screening (if applicable) Result of Breast Screening
Lifestyle
Why we are collecting information about your ethnic group Everyone belongs to an ethnic group, so all patients are being asked to describe their ethnic group. We are collecting this information to help the NHS and social services to: –
• Understand the needs of patients and service users from different groups and so provide better and more appropriate services for you.
• Identify risk factors – some groups are more at risk of specific diseases and care needs, so ethnic group data can help treat patients and support service users by alerting staff to high-risk groups.
• Improve public health by making sure that our services are reaching all our local communities and that we are delivering our services fairly to everyone who needs them.
• Comply with the law as the race Relations (Amendment) Act 2000 gives public authorities a duty to promote race equality and good race relations, and ethnic monitoring is important in making sure that race discrimination is not taking place.
• The 16 ethnic groups used are standard categories for collecting ethnic group information. Using these codes will help us to compare information about the groups using our services with information from the census which tells us about our local population.
The list of groups is designed to allow most people to identify themselves. The list is not intended to leave out any groups of people, but to keep the collection of ethnic information simple. It is important to us that you can describe your own ethnic group.
If you need to complete any of the boxes labelled ‘any other group’ then please give some details so that we can better understand your needs.
You do not have to complete the question but providing this information is very important. It will help us with diagnosis and assessment of your needs, and it will also help us to plan and improve our service. The information you provide will be treated as part of your confidential NHS record. The NHS and social services have strict standards regarding data protection and your information will be carefully safeguarded.
If you have any concerns or questions regarding this request or want to make any comments or complaints about the collection of this information, or the way in which you have been treated by staff requesting this information, please contact the Practice Manager.
Online Access Information Before you apply for online access to your records, there are some things to consider.
Although the chances of any of these things happening are very small, you will still be asked that you have read and understood the following before you are given log in details.
Things to consider:
• Forgotten History
There may be something you have forgotten about in your records that you may find upsetting.
• Abnormal results or bad news
If your GP has given you access to test results and 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 up to you whether you share information with others – perhaps family members or carers. Its 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 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 on your record that is not about you or notice other errors, please log out of the system immediately and contact the practice as soon as possible.
More information
For more information about keeping your healthcare records safe and secure, you will find a helpful leaflet produced by the NHS in conjunction with the British Computer Society:
Keeping your online Health and social care records safe and secure.
www.nhs.uk/nhs-services/gps/view-your-gp-health-record/
Application for online access to my medical record I wish to have access to the following online services (please tick all that apply) I wish to access my medical record online and understand and agree with each statement (please tick all that apply)
Information for new patients: about your Summary Care Record (SCR) Dear Patient,
If you are registered with a GP Practice in England, you will already have a Summary Care Record (SCR), unless you have previously chosen not to have one. It will contain key information about the medicines you are taking, allergies you suffer from and any adverse reactions to medicines you have had in the past.
Information about your healthcare may not be routinely shared across different healthcare organisations and systems. You may need to be treated by health and care professionals who 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 a Summary Care Record can help by providing healthcare staff treating you with vital information from your health record. This will help the staff involved in your care make better and safer decisions about how best to treat you.
You have a choice
You have the choice of what information you would like to share and with whom.
Authorised healthcare staff can only view your SCR with your permission. The information shared will solely be used for the benefit of your care.
Your options are outlined below: please indicate your choice on the form attached (your signature is needed on this form)
EXPRESS CONSENT for medication, allergies and adverse reactions only. You wish to share information about medication, allergies for adverse reactions only.
EXPRESS CONSENT for medication, allergies, adverse reactions and additional information. You wish to share information about medication allergies for adverse reactions and further medical information that 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 and who should be contacted for more information about you.
EXPRESS DISSENT for Summary Care Record (opt out). Select this option, if you DO NOT want any information shared with other healthcare professionals involved in your care.
If you choose not to complete this consent form, a core Summary care Record (SCR) will be created for you, which will contain only medications, allergies and adverse reactions.
Once you have completed the consent form, please return it to your GP Practice.
You are free to change your decision at any time by informing your GP Practice.
Do you want a Summary Care Record?
Why does the receptionist ask me for a brief description of what’s wrong? It is not the case of our receptionists being nosey!
The reception staff are members of the practice team and it has been agreed they should ask patient a ‘brief reason why they need to be seen’. Reception staff are trained to ask certain questions in order to ensure that you receive:
• The most appropriate medical care
• From the most appropriate health professional
• At the most appropriate time
Receptionists are asked to collect brief information from patients
• The help doctors prioritise house visits and phone calls
• To ensure all patients receive the appropriate level of care
• To direct patients to see the nurse or other health professionals rather than a doctor where appropriate
Reception staff, like all members of the team, are bound by confidentiality rules
• Any information given by you is treated in the strictest confidence
• The practice takes any breach of confidentiality very seriously and will deal with it accordingly
• You can ask to speak to a receptionist in private away from the reception counter
• However, if you feel an issue is very private and do not wish to say what this is then we will respect your decision.
We would like to thank you for your understanding and co-operation.