www.heathvillesurgery.co.uk
OR
www.aspencentre.co.uk
Practice Addresses
Main surgery Address
Aspen Centre, Horton Road, Gloucester, GL1 3PX.
Tel: 01452 337733 Fax: 01452 337734
Branch Surgery Address
38 Warwick Avenue, Tuffley, Gloucester, GL4 0SL.
Tel: 01452522959 Fax: 01452 410758
Practice Manager: Mrs C R Barnfield
New Patient Registration Application Form
PATIENT/FAMILY NAME:
Please write your name below.
___________________________________________
1
Heathville Medical Practice
www.heathvillesurgery.co.uk
In order for us to process your application we require the following
information:
Please note proof of identity (photo) & residency is required & the
following documents are acceptable:
For identification purposes we require one of the following:
 Photographic Driving Licence
 Passport
 EU National’s ID card
 Student ID card
 Police Warrant Card
 NHS Smartcard
For






address verification we require one of the following:
Council Tax Bill (within the last 6 months)
Utility Bill (not mobile phone)
Benefits Agency correspondence
HM Custom’s correspondence
Letter from Solicitor confirming address
Disabled Drivers Pass/Parking Permit
ALL OF THESE DOCUMENTS PRESENTED FOR REGISTRATION
PURPOSES ARE ACCEPTABLE BY THE HOME OFFICE.
(New Patients) Please use the tick box below to check all the necessary forms and
supporting documents are completed and attached before bringing into the surgery.
Incomplete or incorrectly completed registration documents cannot be accepted
and will delay your registration with the practice.
Identification
Address
Verification
GMS1
Purple &
white
form –
all
details
filled in?
Registration
Booklet
completed
if required?
All the
forms for
every
family
member?
PLEASE COMPLETE/TICK TO CONFIRM WHICH DOCUMENTS YOUR ARE PRESENTING
2
Please answer these questions as fully and accurately as possible as this will be our
only medical record for the doctors to use until your notes arrive, which may take
some time.
Full Name:
Telephone Number:
Work Number:
Mobile Number:
E-mail Address:
Next of Kin:
Next of Kin Contact Number:
Date of Birth:
Previous / Mother’s surname if
different:
Male:
Marital
Status:
Your
height:
Your
Religion:
Female:
Gender:
Feet / inches
cm
Other residents of your home:
Stones / lbs.
Your
weight:
C of E
Catholic
Other Christian (state)
Buddhist
Sikh
Jewish
Jehovah’s Witness
No religion
Your Ethnic Origin:
kg
Hindu
Muslim
Other religion (state)
White (UK)
9i0
White (Irish)
9i1%
White (Other)
9i2%
Caribbean
9i3
African
9i4
Asian 9i5
Other Mixed
Background 9i6%
Indian /
Brit Indian 9i7
Pakistani /
Brit Pakistani 9i8
Bangladeshi / Brit
Bangladeshi 9i9
Other Asian
Background 9iA%
Other Black
Background
Chinese
9iE
Other
9iF%
Ethnic Category
not stated 9iG
(select one)
Your main or 1st language
Spoken / Understood:
(select one)
Polish
Ukrainian
3
English
Hindi
Gujurati
Urdu
French
German
Spanish
Other:
(Please
Specify)
Bengali
/Sytheti
Punjabi
Smoking, Alcohol Consumption and Exercise:
Are you currently a
smoker?
Yes
No
Have you ever been a
smoker?
If so, how many cigarettes / cigars /
tobacco do you smoke in a week?
If you are a smoker and want to stop, please ask for
information about local smoking cessation services.
How often do you exercise?
No. times per
week
Yes
No
How much alcohol do you drink in a
week (Units)?
(One unit = 1 small glass of wine, a
single measure of spirits, or 1/2 a
pint of beer)
Type(s)
of
exercise:
Units
Drinks
ALCOHOL CONSUMPTION
Pint of Regular
Beer/Lager/Cider
Alcopop or
Can of Lager
Glass of Wine
(175 mls)
Single Measure
of Spirits
Bottle of Wine
2 UNITS
1.5 UNITS
2 UNITS
1 UNIT
9 UNITS
Questions
How often do you have a drink that
contains alcohol?
How many units do you have on a
typical day when you are drinking?
How often do you have 6 or more
units on one occasion?
Your Medical Background:
What illnesses have
you had & When?
What operations
have you had and
When?
Do you have any
medical problems at
present?
4
0
1
2
3
4
Never
Monthly
or less
2-4
times
per
month
2-3 times
per week
4+
times
per
week
1-2
3-4
5-6
7-8
10+
Never
Less
than
monthly
Weekly
Daily
or
almost
daily
Monthly
Please list any
tablets, medicines or
other treatments you
are currently taking:
(incl. dose +
frequency)
Are you able to
administer your own
medicines?
PATIENT ACCESS
To allow on line
booking and on line
ordering of
medication.
Staff use only
No – please detail specific issues (e.g. swallowing, opening
containers)
Yes
Yes
If you want to use our on-line facilities, please alert the
receptionist/HCA as you will need to complete an online access
form.
YOU MUST HAVE YOUR ID AVAILABLE
No
Has the patient completed an application for online access to their medical records?
This form will need to be scanned into their records.
Do you look after someone who is ill, frail, disabled or mentally ill?
If yes, Name of person you are caring for_____________________
Are you being cared for? Do you have someone who looks after
you because you are ill, frail, disabled or mentally ill?
If Yes, Name of your carer_______________________________
CARERS
Are you a carer?
Would you like to
receive help?
The practice is very keen to identify carers, especially those people
who may be caring without help or support.
Yes/No
With your permission, the practice will add you to the register of
Carers on its computer system.
I give my permission to have my name added to the practice
register as a carer or as a patient who is being cared for.
Signed____________________________________________
The practice has information relating to services available to carers,
please ask at reception for details.
Is there a young
Carer in the
household?
Yes/No
We can refer them on to www.glosyoungcarers.org.uk or you can
telephone 01452 733060.
Diabetes
Are there any
serious diseases that
affect your Parents,
Brothers or Sisters
(tick all that apply)
5
Heart
Attack
Breast Cancer
Thyroid Disorder
Heart attack under age
of 60
High Blood Pressure
Bowel Cancer
Asthma
Stroke
Any other important Family Illness?
IMMUNISATIONS
What
immunisations
have you had?
(please tick all
that apply)
Please complete
for Children.
Diphtheria
Measles
Whooping Cough
German Measles
Pre-school booster
Tetanus
Polio
Triple vaccine (Diphtheria,
Tetanus & Pertussis) –
3 doses
MMR
Which school does your
child attend?
Specific Needs:
Please detail below any specific needs you have so the Practice can ensure they are identified and
accommodated by taking the appropriate action:
Please state any Sensory Impairment
you have
(i.e. Speech, Hearing, Sight):
Are you an ‘Assistance Dog’ User?
Please state any Physical disabilities
you have:
THE PRACTICES AT BOTH ASPEN CENTRE AND TUFFLEY SURGERY HAVE DISABLED ACCESS
Please state any Mental disabilities
you have:
Please state any Religious or Cultural
needs:
Do you require the help of a
Translator / Interpreter?
Please allow at least 72 hours for us
to arrange the interpreter to be
present at your appointment.
British Sign Language interpreter
required
Yes
No
Please state your Language;__________________________
Yes
No
Yes
No
Yes
No
Please state any allergies and
sensitivities you have:
Do you have a “Living Will”
(a statement explaining what medical
treatment you would not want in the
future)?
Have you nominated someone to
speak on your behalf (e.g. a person
who has Power of Attorney)?
6
Women only:
If “Yes”,
can you please bring a written copy of it
to your New Patient Consultation
Date
If “Yes”, please state their name / address / phone
number:
When was your last smear done and
by whom?
NHS England’s Care Data – Registering an
objection
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. (You can ask the receptionist for this)
The NHS England’s care.data patient information leaflet can be found in our surgery
waiting room; on our website www.heathvillesurgery.co.uk or on the NHS England
website (www.england.nhs.uk/ourwork/tsd/care-data/).
Patient Care Data
If you do not want information that identifies you to be shared outside your GP
practice, you can ask your practice to make a note of this in your medical record. This
is called an objection. An objection will prevent your confidential information being
used other than where there are exceptional circumstances or where the law allows
your information to be shared.
PLEASE ASK RECEPTION FOR AN OPT OUT
FORM IF YOU DO NOT WANT YOUR DATA
SHARED
You records will automatically be set as agreeing to this if
you do not opt out.
For staff use only
Staff Sign: ____________
Are you happy to have a Data
Care Record?
7
Opt out form completed Yes/No
Preferences set on EMIS web Yes/No
Dates added:
Codes to opt out:
’Dissent from secondary use of GP patient identifiable data’
code: 9Nu0
Dissent from disclosure of personal confidential
data by Health and Social Care Information Centre’
code: 9Nu4
YES
Patient Signature
Heathville Medical Practice offers the choice of having a summary care record.
The new NHS Summary Care Record has been 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 contains basic information about:
Any allergies you have
Unexpected reactions to medications
And any prescriptions you have received
The intention is to help clinicians in A&E Departments and ‘Out of Hours’
health services to give you safe, timely and effective treatment. Clinicians will
only be allowed to access your record if they are authorised to do so and even
then, only if you give your express permission. You will be asked if healthcare
staff can look at your summary care record every time they need to, unless it
is an emergency, for instance if you are unconscious.
Children under the age of 16
Summary Care Record
Patients under 16 years will not receive this form, but will have a summary
care record created for them unless we are 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. Ask the surgery for
additional forms if you want to opt them out.
You do not have to have a summary care record, although you are strongly
recommended to consider this choice. If you are happy for a summary care
record to be set up for you then you need take no further action. If you want
to opt out now, however, please tick the box below and return the form to
reception as soon as possible.
For more information please visit www.nhscarerecords.nhs.uk
PLEASE ASK RECEPTION FOR AN OPT
OUT FORM IF YOU DO NOT WANT A
SUMMARY CARE RECORD
You records will automatically be set as agreeing to
this if you do not opt out.
Opt out form completed
Yes/No
FOR STAFF USE ONLY
Staff Sign____________
8
Code to be added to records: Express Dissent for Summary Care Record
dataset upload .9Ndo or use the Sharing Consent button for SCR – this is
located on the registration page.
Patient Participation Group
The Practice is committed to improving the services we provide to our patients.
To do this, it is vital that we hear from people about their experiences, views, and ideas for making services
better.
By expressing your interest, you will be helping us to plan ways of involving patients that suit you.
It will also mean we can keep you informed of opportunities to give your views and up to date with
developments within the Practice.
If you are interested in getting involved, please tick the box below and we will arrange for the Practice Patient
Participation Group Application Form to be given to you at your initial consultation.
I am interested in becoming involved in the Practice
Patient Participation Group
YES
NO
TEXT REMINDERS (NEW FOR 2015)
We now offer a service to remind you of your surgery appointment by texting a reminder to your mobile
telephone. A confirmation message will be sent when you book your appointment which will read as shown in
the example below:
Next appointment with Dr Smith at 10.20 on 3rd March 2015
A reminder message will then also be sent approximately 48 hours prior to your appointment.
Please complete if you want to take advantage of this new service
Name:
Address:
Mobile Number
I give consent for my mobile telephone number to be used for text messaging of appointments: YES/NO
Please note that it is your responsibility to advise the surgery of any change to your mobile phone number and
that we are only able to register patients aged 16 years and over for this service.
SIGNED:
ELECTRONIC PRESCRIPTIONS (New for 2015)
We are now live on the Electronic Prescription Service which means that your prescription will no longer be
printed out. It will be ready for collection from the Pharmacy of your choice, 48 hours after we have received
the prescription request.
Should you wish to partake in the Electronic Prescription Service, please give us a call on 01452 337733 to
inform us of your nominated Pharmacy.
If you have any further questions, please do not hesitate to give us a call. Thank You.
An appointment for a new patient health check will complete your registration
Please allow 48 hours after this appointment for your registration to be completed
in full.
Thank you for completing this form
For more information about the services we offer, please refer to your new patient pack
or see our website: www.heathvillesurgery.co.uk
9
For Office Use only
CHECKLIST: Please check and verify the following information from the
Registration form (GMS1 –purple)
Previous address completed
Yes/No
Date entered UK (if from overseas)
Photo ID checked and in date:
Yes/No
Address ID checked: Yes/No
HAVE YOU CHECKED THAT ID IS RELEVANT AND CONFIRMS
RESIDENCY? Yes/No
Has the patient signed the Data Sharing & Summary Care Record Section?
Has the patient completed the Opt out forms (if relevant)?
Have you added the patient to the carers register?
Have you nominated a carer to this patient?
REGISTRATION ACCEPTED BY:___________________
REGISTRATION CHECKED BY:_____________________
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