NEW PATIENT REGISTRATION FORM
Title: Mr
Master
Mrs
Ms
Miss
Other ______________________
(Please tick)
Surname: ________________________________________
First Name: _______________________________________
DOB:
Age:
How many adults in the household: ……………….
How many children in the household: ……………
Middle Name(s): __________________________________
Previous / Surname: _______________________________
NHS NO:
Marital Status:
Single
Married
Co-habiting
Town of Birth:
Contact Details:
Widowed
Separated
Divorced
Country of Birth:
Home:
Mobile:
Work:
Address:
Postcode:
Email:
Previous address:
Postcode:
Previous Doctors:
Postcode:
NEXT OF KIN / EMERGENCY CONTACT DETAILS:
Name: _____________________________________________
Relationship: ________________________
Address: ___________________________________________________________________________________
___________________________________________________________________________________________
Postcode: _________________________________
Is this person your carer:
YES
NO
Telephone: ____________________________________
If YES is this your main carer:
YES
NO
Repeat Medication: If you are on repeat medication please make an appointment with your registered Doctor
within six weeks of registering. Please bring to the appointment a list of your current medications
FOR OFFICE USE
Proof of Identification seen:
Type of document seen: _________________________________________
Proof of residency seen:
Type of document seen: _________________________________________
Checked by: _________________________________
Date checked: ________________________________
Registered with Dr _______________________________ Date of Registration: ________________________
Dispensing: YES
NO
EMIS No: ______________
Actioned by: _________________________
Ethnic Group – 16+1 codes
What is your ethnic group? Choose ONE section from A to E, then tick the
appropriate box to indicate your ethnic group.
A: White
British
Irish
Any other White background (please write in)
B: Mixed
White & Black Caribbean
White & Black African
White & Asian
Any other mixed background (please write in)
C: Asian or Asian British
Indian
Pakistani
Bangladeshi
Any other Asian background (please write in)
D: Black or Black British
Caribbean
African
Any other Black background (please write in)
E: Chinese or other ethnic group
Chinese
Any other (please write in)
Not Stated
This is one unit of alcohol…
…and each of these is more than one unit
AUDIT – C
Scoring system
Questions
0
1
2
3
4
How often do you have a drink containing alcohol?
Never
Monthly
or less
2-4
times
per
month
2-3
times
per
week
4+
times
per
week
How many units of alcohol do you drink on a typical
day when you are drinking?
1 -2
3-4
5-6
7-9
10+
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?
Never
Less
than
monthly
Monthly
Weekly
Daily or
almost
daily
Scoring: A total of 5 indicates increasing or higher risk drinking. An overall total score of 5 or above is
AUDIT–C positive.
If you scored 5 or above please continue with the remaining questions below
Scoring system
Questions
0
1
2
3
4
How often during the last year have you found that
you were not able to stop drinking once you had
started?
Never
Less
than
monthly
Monthly
Weekly
Daily or
almost
daily
How often during the last year have you failed to do
what was normally expected from you because of
your drinking?
Never
Less
than
monthly
Monthly
Weekly
Daily or
almost
daily
How often during the last year have you needed an
alcoholic drink in the morning to get yourself going
after a heavy drinking session?
Never
Less
than
monthly
Monthly
Weekly
Daily or
almost
daily
How often during the last year have you had a
feeling of guilt or remorse after drinking?
Never
Less
than
monthly
Monthly
Weekly
Daily or
almost
daily
How often during the last year have you been unable
to remember what happened the night before
because you had been drinking?
Never
Less
than
monthly
Monthly
Weekly
Daily or
almost
daily
Your
score
Score
Your
score
Scoring system
Questions
0
Have you or somebody else been injured as a result
of your drinking?
Has a relative or friend, doctor or other health worker
been concerned about your drinking or suggested
that you cut down?
1
2
Yes,
but not
in the
last
year
Yes,
but not
in the
last
year
No
No
3
4
Your
score
Yes,
during
the last
year
Yes,
during
the last
year
Total
Scoring: 0-7 Lower Risk, 8-15 Increasing Risk, 16-19 Higher Risk, 20+ Possible dependence
Smoking Status
Please tick the entry which best describes your smoking status:
(Tick)
Never Smoked Tobacco
Trivial Smoker
Light Smoker
Moderate Smoker
Heavy Smoker
Very Heavy Smoker
Pipe Smoker
Passive Smoker
Ex-Smoker
< 1 cig/day
1-9 cigs/day
10-19 cigs/day
20-39 cigs/day
40+ cigs/day
Number of Grams:
Would you like help and advice to stop smoking?
No
If yes, a member of our Nursing team will be in touch soon
Yes
Signed:
Date:
Print Name:
DOB:
Registering for Access to Online Services
Patient Access is a 24 hour online service that enables you to view, book and cancel appointments at both the Market
Deeping and Glinton Surgeries and order your repeat prescriptions from home, work or on the move — wherever you
can connect to the internet, day or night, 24 hours a day.
In order to access the Patient Access services you are required complete the form below and hand it into your local
surgery, where your application will be processed and a letter produced with your registration details.
This service is now available for children up to 13 years of age and for those who are 16 years of age and older.
th
Parents / Guardians are able to register their children under the age of 13 years but once the child reaches their 13
Birthday this access will be removed along with the Mobile Number and Email address given below; this is to
ensure that patient confidentiality is maintain as best as possible and you will receive prior notification from the
Practice before this access is removed. The requesting parent/guardian must be registered at the same address as
the child in order to access this service.
For now, this service is not available for 13 to 15 year olds, although they will be able to re-register in their own right
th
from their 16 birthday.
1.
I would like to sign up for Online services
Patients Full Name:
Parent/Guardian’s Full Name if application is for a
child under 13:
Date of Birth:
Address:
Telephone No (Patient or Parent/Guardian if
application is for a child under 13):
Email Address (Patient or Parent/Guardian if
application is for a child under 13):
Mobile Number (Patient or Parent/Guardian if
application is for a child under 13):
(Please Tick)
I will collect from the Surgery
Collection of Login Details:
Please Send them to the
Registered Address
Signature (Patient or
Parent/Guardian if application is
for a child under 13):
Date:
For Office use:
Patient Record Update by:
Date:
SMS (Short Message Service) Text Messaging
Only for completion by patients aged 16 and over please
We are always looking at ways to improve our communication to patients.
SMS text messaging is currently being used by other organisations (including dentists, banks and schools)
for appointment reminders and release of general information and we are able to use this facility, with your
permission.
Care will be taken to ensure that no personal information is released using this service and the Practice will
continue to observe the strictest controls with regard to holding your personal information in confidence.
Initially, an SMS text message will be sent containing your appointment details once you have booked an
appointment. A further message will be sent 48 hours before the appointment is due as a reminder.
In the future, we will be looking to introduce a more interactive form of SMS text messaging which will allow
you to cancel your appointment by text if you are no longer available to attend. This facility will also allow
us to send you health promotion initiatives such as flu jabs and NHS Health Check invitations.
If you have a mobile phone, are over 16 and would like to receive SMS messages then please complete the
slip below and hand it in at reception.
You may withdraw your consent at any time by notifying Reception either verbally or in writing.
I would like to receive SMS messages Appointment Reminders and in future Health Promotion initiatives
when they are introduced.
I fully understand that it is my responsibility to provide The Deepings Practice with any change of mobile
phone number.
Surname:
Forename(s):
Date of Birth:
Mobile Number:
Address:
Patient Signature:
Date:
Disclaimer
If you agree to the Practice contacting you via the telephone number provided above, we agree to adhere to the following:
1.
The telephone number you have provided will only be used by the practice in relation to the healthcare services offered by the
practice. You will not be contacted in relation to any other types of products or services and your information will not be passed onto any other
parties.
2.
If at any time you would like to opt-out of the above service, please make a personal request to the practice and you will be opted out
of the service within 48 hours. We would ask that you provide your reason for opting out to help us review and improve the service in the future.
For Office use:
Patient Record Update by:
Date:
Your emergency care summary
New patient letter
Dear Patient
Summary Care Record – your emergency care summary
The NHS in England is introducing the Summary Care Record, which will be used in emergency care.
The record will contain information about any medicines you are taking, allergies you suffer from and any
bad reactions to medicines you have had to ensure those caring for you have enough information to treat
you safely.
Your Summary Care Record will be available to authorised healthcare staff providing your care anywhere in
England, but they will ask your permission before they look at it. This means that
if you have an accident or become ill, healthcare staff treating you will have immediate access to important
information about your health.
Your GP practice is supporting Summary Care Records and as a patient you have a choice:
• Yes I would like a Summary Care Record – you do not need to do anything and a Summary
Care Record will be created for you.
• No I do not want a Summary Care Record – enclosed is an opt out form. Please complete
the form and hand it to a member of the GP practice staff.
If you need more time to make your choice you should let your GP Practice know.
For more information talk to our Patient Advice and Liaison Service (PALS) on 0845 602 4384, GP
practice staff, visit the website www.lincolnshire.nhs.uk or www.nhscarerecords.nhs.uk or telephone the
dedicated NHS Summary Care Record Information Line on 0300 123 3020.
Additional copies of the opt out form can be collected from the GP practice, printed from the website
www.nhscarerecords.nhs.uk or requested from the dedicated NHS Summary Care Record Information
Line on 0300 123 3020.
You can choose not to have a Summary Care Record and you can change your mind at any time
by informing your GP practice.
If you do nothing we will assume that you are happy with these changes and create a Summary Care
Record for you. Children under 16 will automatically have a Summary Care Record created for them
unless their parent or guardian chooses to opt them out. If you are the parent or guardian of a child
under 16 and feel that they are old enough to understand, then you should make this information
available to them.
Yours sincerely,
The Deepings Practice
NHS England’s Care.Data – Opt-Out Form
NHS England’s care.data system aims to provide timely, accurate information to citizens,
clinicians and commissioners about the treatments and care provided by the NHS.
Please refer to the NHS England’s care.data patient information leaflet before completing this
form. The NHS England’s care.data patient information leaflet can be found on the NHS
Choices website (www.nhs.uk).
OPT-OUT FORM – Confidential
A.
Please tick this box if you do not want your GP to release any of your GP record to
the Health and Social Care Information Centre for purposes of the care.data
system. (9Nu0)
B.
Please tick this box if you do not want the Health and Social Care Information
Centre to disclose to any accredited third parties any information they hold on you
(from any NHS source). Please note that, in general, such data would only be
made available to accredited third parties in anonymised, pseudonymised or
aggregated form. (9Nu4)
C.
Please complete in BLOCK CAPITALS
Title: __________ Surname / Family Name: __________________________________
Forename: _______________________________ Date of Birth __________________
Address: ______________________________________________________________
Postcode: __________________________ Phone No: _________________________
Signature: ____________________________ Date: ___________________________
D.
If you are filling out this form on behalf of another person or a child, their registered GP will
consider this request. Please ensure that you fill out their details in section C and your
details in section D.
Your Name: ___________________________________________________________
Your Signature: ________________________________________________________
Relationship to Patient: __________________________ Date: ___________________
FOR PRACTICE USE ONLY:
Patient record updated with Read Code 9Nu0 “Dissent from secondary use of GP patient
identifiable data and Read Code 9Nu4 “Dissent from disclosure of personal confidential data by
Health and Social Care Information Centre”
Date completed: _________________________ Initials ____________________________
CHECK LIST WHEN REGISTERING
(Tick)
Catchment Area – please check that you are within our boundary by
going to our website www.deepingspractice.co.uk and clicking on the
New Patient tab. By putting in your postcode a message will be displayed
which will inform you if you are within in our boundary.
Photographic ID – Please bring photographic ID to show at reception
such as:
 Passport
 Driving Licence
(only 16 years of age and over)
Proof of address – please provide proof of address. This must contain
both your new address and your name. Suitable documents are:
 Council Tax form
 Solicitors letter
 Bank Statement
(only 16 years of age and over)
GS1 form – please sign at the base of the form.
SMS Text Messaging - If you would like to receive a text message
reminding you of an appointment you have booked, please fill in the SMS
consent form.
Online patient access – If you would like to book an appointment or
order repeat prescriptions online please fill in the Online Access form.
Summary Care Record Opt-Out form – If you would like to opt-out of
sharing your record please fill in the Opt-out form. (Please read the
enclosed information paperwork).
Care.Data Opt-Out form – If you would like to opt-out please fill in the
enclosed Opt-Out form. (Please read the enclosed information
paperwork).