Which sections should be completed?
Part A – all sections that apply.
Part B – this section is optional, but will help the GP provide the best care.
Part C – only complete these sections if you do not normally live in the UK.
You may be contacted by the GP surgery if you do not complete all the relevant sections
Section 1 – Who is registering? Are you registering.. Only provide your details if you are registering someone else.
Section 2 – Details of patient registering Date of Birth What is your sex as recorded on your NHS record? If you have no fixed address, please tick yes Current Address
The practice catchment area is E17, any registrations of patients residing outside of this postcode will not be registered Name and address of UK GP surgery you registered with
Have you ever lived somewhere else in the UK? Last address in the UK
The NHS and your GP surgery can use these details to
call, text or email you about health care services.
All phone numbers must be registered in the UK
Email
Section 3 – Patients under 18 years Is this registration for a child under the age of 12 month? Where were they born? Where was the mother living when the baby was born?
Is this registration for a patient under the age of 18? Do you attend any of the following? School / Nursery address
Are any of these involved in your care? Have you had all your routine vaccinations? Did you get your routine vaccinations in the UK?
Section 4 – Additional information What is your ethnic group? Ethnicity Ethnicity Ethnicity Ethnicity Ethnicity Have you registered with a UK GP before? If you have moved to the UK, what date did you arrive? Have you ever served in the UK Armed Forces or were you ever registered with a Ministry of Defence GP in the UK or overseas? If you were given a FMED133A form (sometimes called an FMED1 form) when you left the UK Armed forces, you should give this to your GP surgery. Do you need an interpreter for your appointments? British Sign Language (BSL) Are you a carer? What type of carer are you? Do you have a carer? What type of carer are you? What pharmacy do you want your prescriptions sent to?
Pharmacy address
You can sometimes collect your prescription items from
your GP surgery instead of having to go to a pharmacy.
Your surgery may discuss this with you
Do you live more than 1 mile from your nearest pharmacy? Would you have serious difficulty getting medicines or appliances from your nearest pharmacy? Your GP surgery needs permission to share important information from your GP record. This is called a Summary Care
Record (SCR). Your SCR can only be shared with health and care staff across England who are providing you with direct
care. It gives them access to vital information from your GP record
Do you want important information from your GP record to be available to other health and care professionals?
Section 5 – Patient health Have you ever had any of these conditions? What best describes you? What date did you stop smoking? How often do you drink alcohol? How often have you had six or more units of alcohol on a single occasion in the last year? What is your weight?
OR
What is your height?
OR
Mental health conditions Optional
Other medical conditions Optional
Give details of any medication you are taking Optional
Are any of these repeat prescriptions? Do you or your carer need to be communicated in an accessible format? For example, braille, audio, large format or EasyRead Tell us what you need Optional
Do you or your carer need any reasonable adjustments to make your visit to the GP surgery accessible? For example, an audible or visual alert in the waiting room, access to a hearing loop or the support of a note taker Tell us what you need Optional
PART C
Section 6 – Patients from abroad Select the statement that applies to you Tick one of the following Enter details from your EHIC
Date of birth Expiry date You can help save lives as a blood or organ donor. Become someone’s lifeline.
Visit www.nhsbt.nhs.uk/lifeline or call us on 0300 123 23 23
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Name
Dr Miss Mr Mrs Ms Prof. Rev.
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Name
First
Middle
Last
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Previous Address
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Email Hidden
Name
First
Last
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Address
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Please give us your previous repeat medication list if possible, a medication review appointment may be needed: Optional
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Total Score: Hidden
Expected due date Hidden
Blood Donation Hidden
Organ Donation Hidden
Which organs would you like to donate: Optional
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Date Hidden
Do you consent to your GP Practice sharing your health record with other organisations who care for you? Hidden
Do you consent to your GP Practice viewing your health record from other organisations that care for you? Hidden
Do you consent to having an Enhanced Summary Care Record with Additional Information? Hidden
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Access to GP Online Services
Important Information – Please read before completing form below
If you wish to, you can now use the internet (via computer or mobile app) to book appointments with a GP, request repeat prescriptions for any medications you take regularly and look at your medical record online. You can also still use the telephone or call in to 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. If you are unable to 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.
During the working day it is sometimes necessary for practice staff to input into your record, for example, to attach a document that has been received, or update your information. Therefore you will notice admin/reception staff names alongside some of your medical information – this is quite normal.
The definition of a full medical record is all the information that is held in a patient’s record; this includes letters, documents, and any free text which has been added by practice staff, usually the GP. The coded record is all the information that is in the record in coded form, such as diagnoses, signs and symptoms (such as coughing, headache etc.) but excludes letters, documents and free text.
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 your GP has given you access to 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.
For further information, please see:www.nhs.uk/NHSEngland/AboutNHSservices/doctors/Pages/gp-online-services.aspx