New Patient Registration V 7 (2024)

Fields marked "REQUIRED" are compulsory. You should only send this form if you are sure that you are eligible to join this practice. Sending this form will NOT automatically register you with the surgery. Your details will be held at the surgery for a limited period of time. Once you have completed your form, please email ID documents to bhccg.clinicalstpeters@nhs.net. To become registered at St Peter’s Medical Centre please can you complete this Registration Form and produce proof of identification with name and current address. • Photographic ID e.g. passport, driving licence, bus pass AND • Proof of address in the form of an up to date utility bill, bank statement, Tenancy Agreement or Solicitors letter (dated within the last 3 months) • Birth Certificate (For registering children) If you are unable to provide any of the above documents, then please speak with a member of the reception team. Sending this form does NOT guarantee or even imply that you will be accepted onto the practice register.

Last Updated: 13/03/2024

Personal Details

Your Previous GP Surgery

If you have never been on an NHS GP list, write 'none'

Have you previously been registered with an NHS GP? *

Yes No

Surgery name *

Surgery address (if unknown - enter area) *

Your address when you registered with an NHS GP *

If you have come from abroad, including Scotland and Northern Ireland, you must provide a date you came otherwise we cannot register you

Date you came to live in the UK

Date you previously left the UK (if relevant)

Permanent resident in the UK *

Yes No

If NO, length of stay in UK

Next of Kin/Dependants

Next of Kin (in UK) *

Name *

Relationship to you *

Their telephone number *

Do you have children under the age of 16? *

Yes No

If yes, please fill in their name, date of birth and gender

Armed forces

Are you returning from the Armed Forces or a military veteran *

Yes No

Address before enlisting

Service/Personnel number and enlistment date

Carer's details

If relevant, we will need consent from the person before we can record their details on your health records – please provide a signed letter from them including name, DOB, address and contact number.

Do family/friends/neighbours rely on you because they have long-term ill health, disability or problems of old age? *

Yes No

Would you like more information about support for carers [ask Reception for a Carer’s Pack]?

Yes No

Do you have a carer? *

Yes No

Do you give consent for the practice to contact your carer (if medically appropriate)?

Yes No

Name of Carer

Telephone number of carer

We will contact your carer to obtain consent for their details to be added to your medical records

Current Medication

If you are taking a repeat medication you will need to speak to a member of our pharmacy team

Are you taking regular medication prescribed by a doctor or nurse? *

Yes No

Please list medication prescribed (if none type N/A) *

Electronic Prescribing

The Electronic Prescribing Service (EPS2) is now available for our patients which means we will be able to send prescriptions electronically direct to your Nominated Pharmacy. Please add your Nominated Pharmacy below

NOMinated pharmacy *

Location/Address *

Past Medical History

Please tick yes or no to the following conditions

Family History

Please answer yes or no if any blood relatives have any of following health problems / diseases

Women ONLY

HPV vaccinations after 01/01/1990, please add dates if known

1st

2nd

3rd

Date of most recent cervical smear

Result of smear

If age 50-65, date of last mammogram

Are you pregnant?

Yes No

If pregnant, date of last period (LMP)

Blood pressure/height/weight/smoking status

Consent for Text (PLEASE READ BELOW)

• I acknowledge that the responsibility for checking my test results still rests with me. •I understand messages are sent via a secure facility over a public network to a personal phone. • I understand I can cancel the text message facility at any time.

I consent to the practice contacting me by text (which may include test results, appointment reminders, health care campaigns and practice updates) *

Yes No

Consent for Email communication (PLEASE READ BELOW)

• I acknowledge that the responsibility for checking my test results still rests with me • I acknowledge if I use a shared email address it is my responsibility to ensure any confidential information is safe. We will send you an automatic verification request via email – please follow instructions carefully by clicking link we send. You will need to answer some security questions. We cannot verify email manually.

I consent to the practice contacting me by email (which may include test results, appointment reminders, health care campaigns and practice updates): *

Yes No

Your Data Matters to the NHS

Information about your health and care helps us to improve your individual care, speed up diagnosis, plan your local services and research new treatments. In May 2018, the strict rules about how this data can and cannot be used were strengthened. The NHS is committed to keeping patient information safe and always being clear about how it is used. You can choose whether your confidential patient information is used for research and planning.

To find out more visit: nhs.uk/your-nhs-data-matters

Summary Care Record (SCR)

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. 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 chose 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.

Having read the above information regarding your choices, please choose one of the options below *

Express consent for medication allergies and adverse reactions only

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

No, I would not like a Summary Care Record (OPT OUT)

How the NHS will use your data

The following questions allow you to tell us how you would like St Peter's Medical Centre to share your medical records with other NHS organisations involved in your care. You can change your preference at any time by contacting the surgery.

Do you consent to St Peter's Medical Centre sharing your medical records with other NHS organisatons caring for you, for the purpose of healthcare ? This is known as sharing out. Default setting No *

Yes No

Do you consent to St Peter's Medical Centre viewing medical records shared by other NHS organisations caring for you, for the purpose of healthcare ? This is known as Sharing In. Default setting No *

Yes No

Additional Information: How you describe yourself?

We want to make sure everyone is treated fairly and equally. That is why we ask you for this additional information. All answers are confidential. It will be included in your medical record but we will not share the information you give us with anyone outside the NHS. We will use the information you provide to improve your care and anonymously to help make decisions about improving services.

Sexual Orintation

How would you describe your Sexual Orientation

Heterosexual / straight

Lesbian / Gay Woman

Homosexual / Gay Man

Bisexual

Non-binary

Prefer not to say

Religion

Communication and access

Do you need additional help to access the surgery and its services ?

Please state the type(s) of impairment you have that may need additional help to access the surgery and its services

Physical Impairment

Visual impairment

Learning disability/difficulty

Hearing Impairment

Other

Alcohol

Alcohol use can affect your health and can interfere with certain medications and treatments. Your answers will remain confidential so please be honest.

Whooley Questions

If you answer ‘yes’ to these questions then you could be suffering from depression. If you would like help with this you can self-refer to the Brighton Wellbeing Service for talking therapy by visiting www.brightonandhovewellbeing.org, by calling them on 0300 002 0060 or by making an appointment with a GP or Nurse at the surgery. If you feel need urgent help as a result of a mental health crisis then you can contact the mental health rapid response service by phoning 0300 304 0078.

During the past month, have you often been bothered by feeling down, depressed of hopeless?

Yes No

During the past month, have you often been bothered by little interest of pleasure in doing things?

Yes No

PPG - Patient Participation Group

St Peter's has an active patient participation group which meets several times a year to work with the Practice to improve our services. This is also a good place to come to learn about plans for new developments. We particularly encourage younger people and people with long term conditions to get involved to help us make our practice accessible to all.

Would you like to join the patient participation group? *

Yes No

Register for Online Services

You can book appointments, order repeat medications and see your prospective medical record if you register for online services.

To register for our online services you will need to complete this section of the form and then visit the practice, bringing with you two forms of identification or email us a copy of the two forms of identification to sxicb-bh.clinicalstpeters@nhs.net. One of these items should include your photograph. We will then issue you a username and password.

WHICH ONLINE SERVICES WOULD YOU LIKE ACCESS TO (PLEASE TICK ALL THAT APPLY)

Order Repeat Prescriptions

Make an Appointment

Cancel an Appointment

Change personal details

Review your medications and known allergies

View Prospective Medical Records

I understand that It is my responsibility to keep my account secure by keeping my details confidential. I will be responsible for the security of the information that I see or download. If I choose to share my information with anyone else, this is at my on risk. I will contact the practice as soon as possible if I suspect that my account has been accessed by someone else without my agreement. If I see information in my record that is not about me or is inaccurate I will contact the practice as soon as possible.I understand that I can terminate my account at any time by contacting the surgery, or change my log in details by re-registering and that this form will be kept on my electronic records I understand that my registration will be revoked if I constantly miss or cancel appointments.

I consent to the practice collecting and storing my data from this form

Authorisation

Today's date *

Signature (please type in your name) *

Are you filling out this form on behalf of someone else? *

Yes No

Your name (If filling in on behalf of someone else)

Contact tel (If filling in on behalf of someone else)

ID documents

To become registered at St Peter’s Medical Centre please can you complete this Registration Form. You do not need to produce any proof of ID unless you are requesting to use our online services for appointment booking, requesting repeat prescriptions and access to your medical records. The proof of ID should have your name and current address. • Photographic ID e.g. passport, driving licence, bus pass AND • Proof of address in the form of an up to date utility bill, bank statement, Tenancy Agreement or Solicitors letter (dated within the last 3 months) • Birth Certificate (For registering children) If you are unable to provide any of the above documents, then please speak with a member of the reception team.

Please confirm which ID documents you will be emailing to sxicb-bh.clinicalstpeters@nhs.net *

Passport

Utility Bill

Driving licence

Tenancy agreement

Identity Card

Bank Statement

Other

Please make sure the form is submitted before closing your browser. You will receive confirmation by text or email when you are registered. Please tick to acknowledge. *

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New Patient Registration V 7 (2024)

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