Registration Pack - Beech Tree Medical Practice

Quote / Testimonial:

Thank you for choosing us as your new GP Surgery.

This Welcome Pack contains the following:

GMS1 Registration Form
New Patient Questionnaire
Information about Summary Care Record/Transferring your electronic health record
Online access to health records request
Application for Third party access to healthcare

We would like to take this opportunity to welcome you to the practice and assure you of a positive patient experience each time you have a need to visit us.

In order for us to complete the registration process, we require Two forms of identification so that we can confirm your name and date of birth is correct. This will help us locate your medical records quickly and efficiently. If you are new to the United Kingdom it will help us obtain your NHS number. Please also supply us with details of your previous GP and your NHS number if you know it.

Adults – Passport, Driving Licence or Birth Certificate
We also require to see proof of your address (e.g. bank statement, council tax bill). These will be photocopied, checked against registration forms and then destroyed.
Children – Birth Certificate or Passport
This will be photocopied, checked against registration forms then destroyed.
Children aged 6 and under
Your child’s immunisation record/history. This information will be entered into our computer system and is extremely important for the welfare of your child.

All new patients who are on regular repeat medication will be required to provide us with copies of current medication use, Any control drugs issued previously will not be prescribed without a clinical pharmacist appointment so please make sure you have enough medication to cover for this as this may be over a 6 week wait.

If you have any further questions regarding the registration process please contact the surgery. Please note we cannot process your registration until we have seen and checked all your ID.

Yours sincerely,
Beech Tree Medical Practice

Patient Name

First Last

Date of Birth

Day

Month

Year

NHS Number (If known) Optional

Beech Tree Medical Practice offers its patients the choice of having a Summary Care Record.

The new NHS Summary Care Record is being introduced to help deliver better and safer care and give you more choice about who you share your healthcare information with.

What is the NHS Summary Care Record?

The Summary Care Record will contain basic information about any allergies you may have, unexpected reactions to medications and any prescriptions you have recently received. The intention is to help clinicians in Accident and Emergency Departments and Out of Hours health services to give you safe, timely and effective treatment.

Children under the age of 16

Patients under 16 years will not receive this letter, but will have a Summary Care Record created for them unless their GP surgery is advised otherwise. If you are the parent or guardian of a child then please either make this information available to them or decide and act on their behalf.

You do not have to have a Summary Care Record, although you are strongly recommended to consider this choice. If you decide to proceed, but at any time in the future you, or a child you are responsible for, change your mind and choose not to have a Summary Care Record, all you need to do is write to your Surgery informing them of your decision to Opt Out. If you have already told your Surgery that you wish to Opt Out and you wish this to remain in place you need take no further action.

Additional information included in the SCR

The additional information set has been defined and signed off by clinical groups and suppliers. SCRs with additional information incorporate individual coded items and associated free text and will include:

• Reason for medication

• Significant medical history (past and present)

• Anticipatory care information (such as information about the management of long term conditions)

• Communication preferences

• End of life care information

• Immunisations

Please tick a box so we can record your Summary Care Record preference

No, I would not like to have a Summary Care Record

Yes, I would like to have a Summary Care Record

Yes, I would like a Summary Care Record with Additional Information

If you want a basic Summary Care Record you do not have to do anything, it will automatically be created for you.

Electronic Prescription Service

We are now using this new service, please see your local chemist about registering for electronic prescriptions. A new way to get your medicines and appliances.

The Electronic Prescription Service (EPS) is an NHS service. It gives you the chance to change how your GP sends your prescription to the place you choose to get your medicines or appliances from.

What does this mean for you?

• If you collect your repeat prescriptions from your GP you will not have to visit your GP practice to pick up your paper prescription. Instead, your GP will send it electronically to the place you choose, saving you time.

• You will have more choice about where to get your medicines from because they can be collected from a pharmacy near to where you live, work or shop.

• You may not have to wait as long at the pharmacy as there will be time for your repeat prescriptions to be ready before you arrive.

Is this service right for you?

Yes, if you have a stable condition and you:

• don’t want to go to your GP practice every time to collect your repeat prescription.

• collect your medicines from the same place most of the time or use a prescription collection service now.

It may not be if you:

• don’t get prescriptions very often.

• pick up your medicines from different places.

How can you use EPS?

You need to choose a place for your GP practice to electronically send your prescription to. This is called nomination. You can choose:

• a pharmacy

• a dispensing appliance contractor (if you use one)

• your dispensing GP practice (if you are eligible)

Ask any pharmacy or dispensing appliance contractor that offers EPS to add your nomination for you. You don’t need a computer to do this.

Are you completing this for for a child?

Yes

New Patient Questionnaire – Adult (16 years +)

Personal Details

Name

First Last

Date of birth

Month

Day

Year

Contact Number

Enter Email Confirm Email

Occupation

Place of Birth

Address

Street Address Address Line 2 City Postcode Country

Photo ID and Proof of Address

Drop files here or

Max. file size: 100 MB, Max. files: 2.

Please upload 2 files. File number 1 – Photo ID File number 2 – Proof of Address

Previous GP

Have you ever been registered with a GP in the UK?

Yes

Previous GP Surgery Name

Address

Street Address Address Line 2 City Postcode Country

Are you a permanent UK resident?

Yes

Date of entry to UK

Day

Month

Year

Next of Kin

Name

First Last

Relationship to you

Contact number

Carers

Do you look after or support someone who is ill, frail, disabled or mentally ill?

Yes

Who do you care for?

Is this person a patient at Beech Tree?

Yes

Are you looked after or supported by somebody because you are ill, frail, disabled or mentally ill?

Yes

Their Name

First Last

Their contact number

Is this person a patient at Beech Tree?

Yes

Ethnic Origin

Please select your ethnic origin

Please specify

Languages

Do you need an interpreter?

Yes

Language

Current Medication

Please list any medications or other treatments you are currently taking (including medication bought over the counter)

Please note that if you are on any CONTROL DRUGS that these will not be issued without a Clinical pharmacist appointment.

Personal & Family Medical History

Please give details of any serious illness. Please list all past and current medical problems and operations

HIV

Have you had an HIV test?

Yes

Date of last test (approx.)

Day

Month

Year

Result of last test

Positive

Negative

Support Services

Have you, or any member of your family, ever had contact with a Social Worker? If so, what about?

Smoking

Do you smoke?

Yes

How many per day?

Have you ever smoked?

Yes

If you have stopped smoking, give approximate date you stopped

Day

Month

Year

Would you like advice or help to give up smoking?

Yes

A member of staff will be in contact to book a smoking cessation appointment as part of the Warwickshire Stop Smoking Service.

Alcohol

alcohol units

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

How often during the last year have you failed to do what was normally 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 you had been drinking?

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

Your Score

Thank you for taking the time to complete this questionnaire.

Online Access to Health Records Request

In accordance with the UK General Data Protection Regulation (UK GDPR)

Guidance notes – please read before completing this form:

If a child aged 13 or over has ‘sufficient understanding and intelligence to enable him/her to understand fully what is proposed’ (known as Gillick Competence), then s/he will be competent to give consent for him/herself but may wish a parent to countersign as well.

• Patients requiring access to their own record (Sections 1, 2 and 6)

• Proxy access to health records where patient has capacity (Sections 1, 3, 5 and 6)

• Proxy access to health records where patient does not have capacity (Sections 1, 4, 5 and 6)

• Parents requiring access to their child’s (age 13-17) record (Sections 1, 3, 5 and 6)

Section 1: Patient details

Name

Title Optional First Optional Last Optional

Date of birth

Day Optional

Month Optional

Year Optional

Address

Street Address Optional Address Line 2 Optional City Optional Postcode Optional

Contact number Optional

NHS number (if known) Optional

Hospital number (if known) Optional

Section 2: Record requested

I wish to have access to the following online services (please tick all that apply):

Booking appointments Optional

Requesting repeat prescriptions Optional

Access to my medical records Optional

I wish to access my medical record online and both understand and agree with each of the following statements (tick):

I have read and understood the information leaflet provided by the organisation Optional

I understand that I will automatically see any new information (prospective records) that is added to my healthcare record. Optional

I will be responsible for the security of the information that I see or download Optional

If I choose to share my information with anyone else, this is at my own risk Optional

I will contact the organisation as soon as possible if I suspect that my account has been accessed by someone without my agreement Optional

If I see information in my record that is not about me or is inaccurate, I will contact the organisation as soon as possible Optional

Section 3: Consent to proxy access to GP Online Services (if patient has capacity)

Name of Patient

First Optional Last Optional

Consent

I give permission to the above person to have my GP practice give them proxy access to the online services as indicated below in Section 5. Optional

• I reserve the right to reverse any decision I make in granting proxy access at any time
• I understand the risks of allowing someone else to have access to my health records
• I have read and understand the information leaflet provided by the organisation

Consent

I/We wish to have access to the health records on behalf of the above-named patient Optional

Name

First Last

Date of birth

Month

Day

Year

Address

Street Address Address Line 2 City Postcode Country

Email Address

Enter Email Confirm Email

Contact number

If more than one person is to be given access then please list the above details

Reason for access

I/We have been appointed by the Court to manage the patient’s affairs and attach a certified copy of the court order appointing me to do so

I am/We are acting in loco parentis and the patient is incapable of understanding the request

I am/We are the deceased person’s personal representative and attach confirmation of my/our appointment (grant of probate/letters of administration)

I/We have written and witnessed consent from the deceased person’s personal

representative and attach Proof of Appointment

I/We have a claim arising from the person’s death (please state details below)

Section 5: Proxy access online services available

I/We wish to have access to the following online services (please tick all that apply):

Booking appointments

Requesting repeat prescriptions

Access to my medical records

Section 6: Proxy declaration

I/We wish to access to the medical record online of the above patient and I/we understand and agree with each statement (tick)

I/We have read and understood the information leaflet provided by the organisation and agree that I/we will treat the patient information as confidential Optional

I/We will be responsible for the security of the information that I/we see or download Optional

I/We will contact the practice as soon as possible if I/we suspect that the account has been accessed by someone without my/our agreement Optional

If I/we see information in the record that is not about the patient or is inaccurate, I/we will contact the organisation as soon as possible. I/we will treat any information which is not about the patient as being strictly confidential Optional

Consent

I declare that the information given by me is correct to the best of my knowledge and that I am entitled to apply for access to the health records referred to above under the terms of the Data Protection Act 2018. Optional

You are advised that the making of false or misleading statements in order to obtain
personal information to which you are not entitled is a criminal offence which could lead to prosecution.

Section 7: Proof of identity

Under the Data Protection Act 2018, you do not have to give a reason for applying for access to your own health records. However, all applicants will be asked to provide two forms of identification, one of which must be photographic identification before access can be set up.

Please speak to reception if you are unable to provide this.

Additional Notes:

Before returning this form, please ensure that you have:

• Signed and dated the form

• Are able to provide proof of your identity or alternatively confirmed your identity by a countersignature

• Enclosed documentation to support your request (if applicable)

Incomplete applications will be returned; therefore, please ensure you have the correct documentation before returning the form.