New Patient Registration Form - Lyme Bay Medical and Dental Practices

Title *

Surname *

First name(s) *

Previous Surname

Birth Town *

Birth Country *

Date of Birth *

NHS number

Sex *

Male

Female

Address *

Postcode *

Telephone landline

Mobile no

Email address

Is this registration for a child? *

Yes No

If this registration is for a child please supply names, relationship and contact details for those that have parental responsibility (We may ask you to provide a birth certificate to evidence this.)

If you are in school or a student please supply the place of education

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

If you are from abroad

If you are returning from the armed forces

Data sharing consent choices

Summary care record (SCR) Your basic details are uploaded to the national NHS database and can be viewed by other health professionals in an emergency. Enhanced share: your full medical record can be viewed electronically by some healthcare professionals treating you elsewhere but using the same clinical system such as Dorset minor injury units or the district nurses.

Summary care record (SCR) *

I would like a summary care record containing details of my medications, allergies and any bad reactions to medications?

I would like an enhanced summary care record containing details of my medications, allergies and any bad reactions to medications plus additional information that may be useful for my care?

I DO NOT want a summary car record (OPT OUT)?

SystmOne Sharing: Do you agree to the sharing of your information for the purposes of your care? *

Yes No

Preferred Pharmacy

Communications

Give us permission to contact you

Allocated GP

All our patients are entitled to see the GP of their choice, but each patient has an allocated Accountable GP; Dr Forbes Watson on their clinical record. This GP has overall responsibility for your care, but you can request an appointment from any GP.

Please tell us about yourself

Have any close relatives (Mother, Father, Sister, Brother only) ever suffered from any of the following? (please select all that apply).

Heart attack

Stroke

Diabetes

High blood pressure

Asthma

Glaucoma

Cancer

Please can you tell us which relative had which illness and if cancer selected could you tell us what sort or cancer, ie breast cancer

Do you smoke? (This includes vaping.) *

Yes No

Have you ever smoked? *

When did you give up smoking (select approximate date i.e. 1/1/2020

How many cigarettes, roll-ups, cigars, pipes did you smoke a day?

How many alcoholic drinks do you drink a week? *

How often have you had 6 or more units if female or 8 or more units if male on a single occasion in the last year? *

How often during the last year have you failed to do what was expected from you because of your drinking? *

How often during the last year have you been unable to remember what happened the night before because of your drinking? *

Has a friend, relative, doctor or health worker been concerned about your drinking and suggested that you cut down? *

Female patients only

NHS Organ Donor Registration

I want to register my details on the NHS Organ Donor Register as someone whose organs/tissue may be used for transplantation after my death. For more information, please ask for the leaflet on joining the NHS Organ Donor Register

NHS Blood Donor Registration

For more information, please ask for the leaflet on joining the NHS Blood Donor Register

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

Signature confirming consent to inclusion on the NHS Blood Donor Register

Date

Preferred address for donation: (if different from above, e.g. place of work)

Postcode

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.

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 of 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

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.

Are you a parent or guardian, filling out this form on behalf of a child under 16?

Name parent or guardian

Relationship to patient:

Signed

Date

Supplementary questions

NON-UK EUROPEAN HEALTH INSURANCE CARD (EHIC), PROVISIONAL REPLACEMENT CERTIFICATE (PRC) DETAILS and S1 FORMS

If you are visiting from another EEA country and do not hold a current EHIC (or Provisional Replacement Certificate (PRC)/S1, you may be billed for the cost of any treatment received outside the GP practice, including at hospital).

Do you have a non-UK EHIC or PRC?

Yes No

If yes, please enter details from your EHIC or PRC below:

Country Code:

Name:

Given Names:

Date of Birth

Personal Identification Number:

Identification number of the institution:

Identification number of the card:

Expiry Date:

PRC validity period

a) From:

b) To:

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 staff.

I have an S1 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.

LYME BAY NEW PATIENT REGISTRATION FORM

Further Information