GMS1 and New Patient Adult Registration Form

Thank you for choosing to join Hampstead Group Practice. You must complete this form accurately as the information provided by you forms part of your medical record. The information you provide is confidential and will be kept confidential.

Last Updated: 13/09/2021

About you

The information you provide is confidential and will be kept confidential.

Title *

Mrs

Miss

Surname *

First Name *

Calling / Preferred Name

Previous surnames ( if any ) *

Sex

Male

Female

Date of Birth *

Birth Town *

Birth Country *

NHS No. ( If known )

Are you aged 40 or above? If so, you will be required to have a new patient health check as part of the registration process. *

Yes No

Current Address

House name / Flat number *

Number & Street *

Town / City *

County *

Postcode *

Country *

Contact Details

Home Telephone *

Mobile Telephone *

Work Telephone

Tracing your previous medical records

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

Your previous address in UK *

Name of previous GP practice while at that address *

Address of previous GP practice *

Please complete this section if you are from abroad

Are you from abroad? *

Yes No

If previously resident in UK, date of leaving (if not applicable - please enter N/A) *

Your first UK address where registered with a GP *

Date you first came to live in UK *

Were you ever registered with an Armed Forces GP?

Please complete this section if you have served in the armed forces and/or been registered with a Ministry of Defence GP in the UK or Overseas.

Please indicate if you have served in the UK Armed Forces and/or been registered with a Ministry of Defence GP in the UK or overseas

Regular

Reservist

Veteran

Family Member (Spouse, Civil Partner, Service Child)

Address before enlisting

Service or Personnel number:

Enlistment date:

Discharge date (if applicable):

NHS Organ Donor Registration

Please tell your family you want to be an organ donor. If you do not want to be an organ donor, please visit www.organdonation.nhs.uk or call 0300 123 23 23 to register your decision

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. Please tick the boxes that apply.

Any of my organs and tissue or

Kidneys

Heart

Liver

Corneas

Lungs

Pancreas

I confirm my consent to join the NHS Organ Donor Register *

Yes No

Date: *

NHS Blood Donor Registration

All blood types are needed, especially O negative and B negative. Visit www.blood.co.uk or call 0300 123 23 23

I would like to join the NHS Blood Donor Register as someone who may be contacted and would be prepared to donate blood. *

Yes No

Have you given blood in the last 3 years?

Yes No

I confirm my consent to join the NHS Blood Donor Register *

Yes No

Date *

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

Personal Details

Your Religion

What is your current occupation / profession ?

Are you registered disabled ?

Yes No

If Yes, please give details of your disability. If not applicable please enter N/A *

Do you have any communication needs?

Yes No

If Yes, please tick the options that apply to you:

I use a hearing aid

I use Bristish Sign Language

I'd like my information in large print

I'd like my information in easy read format

Other

If you selected 'Other' above please provide further details:

Person to be contacted in case of an emergency

Name *

Contact Number *

What is your relationship to this person ? *

Carers

Carers are people who are look after a relative, friend, partner or neighbour who cannot manage on their own. The person they are caring for or supporting may be elderly or ill, have a disability, have learning difficulties or a mental health problem or be a child with special needs

Are you a carer for someone ?

Yes No

If "Yes" are they registered at this Practice ?

Yes No

Name of the person for whom you care

Contact number for that person

Do you have a carer ?

Yes No

If "Yes" are they registered at this Practice ?

Yes No

Name of the Person who cares for you. If not applicable, please enter N/A *

Contact number for that person. If not applicable, please enter N/A *

Medical section

Allergies ( to anything, including medicines )

Height

Weight

Blood Pressure

Past Medical History

Please list any illnesses, operations or other serious medical problems that you have had in the past or have currently. Please include any dates you can remember

Past Medical History

Family History

Is there family history of the following ?

Cervical Screening

Female Only

Have you had a hysterectomy ?

Yes No

If "Yes" please give reasons. Please note that if you had a sub-total hysterectomy and the cervix is still in place you will still need to have regular smears.

When was your last cervical screening test ( Smear test )? Write 'NEVER' if you have not previously had a test

Where was the test taken? (Which clinic/practice if in the UK; which country if outside UK)

What was the result of your last test

When is your next test due ?

Have you ever had an abnormal test or had treatment ?

Yes No

If "Yes" give details and the name of the hospital at which you were treated

Smoking

Smoking puts your health at risk, can shorten your life and cause serious illness.

Do you smoke ?

Yes No

If "Yes" for how many years have you smoked ?

If "Yes" how many cigarettes do you smoke per day ?

If "No" have you ever smoked ?

Yes No

If ‘Yes’, how many cigarettes did you smoke per day?

For how many years did you smoke ?

Please tick this box if you would like an appointment with a smoking cessation adviser

Yes No

Sexual Health

We offer all new patients testing for HIV and hepatitis, on request. Many people with blood borne viruses such as HIV and hepatitis B and C are unaware that they are infected. Knowing your status means you can access treatments to keep you fit and healthy and reduce the risk of complications and transmission.

Please tick this box if you would like us to send you the screening test request forms

Yes No

Chlamydia Screening

Free chlamydia testing is available to men and women under 25 who have ever been sexually active. Testing for chlamydia is done with a urine test or a swab test so you don't always need a physical examination by a nurse or doctor. There is no need for a referral; free self-testing kits are available at reception.

Please tick this box if you would like the receptionist to offer you the self-testing kit

Yes No

Alcohol Use

Alcohol should only be consumed in moderation. Excessive consumption can lead to health problems. *A standard drink of alcohol (around 10mls or 8g) is contained in: 1. A single (25mls) pub measure of spirits 2. Half a pint of normal strength beer or lager 3. A small (85 ml) glass of standard strength wine (12%)

Ethnic Monitoring

Please tick one box, or write your ethnic group in the ‘any other’ space if you feel none of the choices best describe you.

Language

What is your Main Spoken Language? This is the language you speak in your home or family environment, regardless of how well you speak English.

Online Access

Please note this service is currently only available for patients aged 16 and over

Do you wish to have online access for booking appointment, requesting medication & accessing medical records?

Yes No

If ‘YES’, please complete the ‘Patient Online Access Registration Form’ which is available on our website

Electronic Prescribing Service

This Practice is set up for electronic prescription service. This means that for most patients we can send your prescription to your chosen chemist directly saving you having to come down to the practice to collect your prescription. If you would like to use this service, please state your nominated pharmacy below:

Nominated pharmacy ?

Consent for Contact by text and email

Patient Text Messaging Service now includes appointment reminders, test results, health promotion, invitations to take part in research studies (voluntary) and updates. Consent to use this service is required. It is important that you notify the Practice at any time when you change either your mobile number or email address · If you wish to withdraw this consent at any time in the future, you are free to do so. Please contact the Practice should this be the case.

I consent to be contacted by text and email *

Yes No

Data Sharing

The NHS data sharing initiatives that the Practice is involved in are the Summary Care Record (SCR) and Joined-up Health and Care records. Please see details below.

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. Having a Summary Care Record gives health and care professionals, away from your usual GP practice, access to information to provide you with safer care, reduce the risk of prescribing errors and improve your patient experience. 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. You are free to change your decision at any time by informing the Practice. For further information on Summary Care Record, please refer to http://digital.nhs.uk/scr/patients

PLEASE SELECT YOUR PREFERENCE *

Yes, I would like a Summary Care Record - Express Consent for medication, allergies and adverse reactions only

Yes, I would like a Summary Care Record - Express consent for medication, allergies, adverse reactions and additional information

No - I would NOT like a Summary Care Record - Express dissent for Summary Care Record ( Opt Out )

Joined-up Health and Care Records

Health and care organisations across North Central London are working together to use digital technology to improve health and care across Barnet, Camden, Enfield, Haringey and Islington. Having joined-up health and care records means that the health and care professionals involved in your care can see your information and make quicker and safer decisions with you. Only those who need to see your information to support your health and social care will have access to personal information. This could include GPs, social workers, hospital clinicians, community health practitioners, mental health staff and other authorised members of the care team. Each person will only be able to view information relevant to their job. If you are happy for your information to be part of this joined up health and care record, then you don’t need to do anything. However, if you don’t want to be included, you need to take action. Please refer to the ‘Joining up Health Care Records’ leaflet for further information.

National Data Opt Out

Patient data from GP medical records kept by GP practices in England is used every day to improve health, care and services through planning and research, helping to find better treatments and improve patient care. The NHS is introducing an improved way to share this information - called the General Practice Data for Planning and Research data collection. NHS Digital has been directed by the Secretary of State for Health and Social Care to collect and analyse data from GP practices for health and social care purposes including policy, planning, commissioning, public health and research purposes. If you DO NOT want your identifiable patient data (which will be pseudonymised) to be shared for purposes except for your own care, you can opt-out by registering a Type 1 Opt-out with the practce or a National Data Opt-Out, with NHS Digital or both. These opt-outs are different and they are explained in more detail on our website.

How Did you hear about our Practice ?

e.g. web search, NHS choices, word of mouth?

Social media, web search, word of mouth, friend recommendation

Signature

Your Name: *

Date *

If you are filling out this form on behalf of the person listed on page 1, please state your relationship to the person *

Parent

Legal Guardian

Lasting power of Attorney for health and welfare

Not Applicable

SUPPLEMENTARY QUESTIONS - These questions and the patient declaration are optional and your answers will not affect your entitlement to register or receive services from your GP.

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 practic

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.

Yes

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

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. 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:

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.

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GMS1 and New Patient Adult Registration Form

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