Dr T Critchfield Dr J Mayhew Dr M Houska

Dr T Critchfield Dr J Mayhew Dr M Houska

Dr S Pegge Dr R Ponnusami Dr K Lim

Angmering Medical Centre
Station Road
Angmering
West Sussex
BN16 4HL
Tel: 01903-786758
Fax: 01903-779823 / The Coppice
Herne Lane
Rustington
West Sussex
BN16 3BE
Tel: 01903 783178
Fax: 01903 859027

Dear Patient

NAMED ACCOUNTABLE GP

Welcome to our surgery.

You may be aware that from April 2016 all practices are required to provide all patients with a named GP who will have overall responsibility for their care.

Your named accountable GP is Dr ______. Your named accountable GP will have overall supervision for the care and support that our surgery provides to you. This does not prevent you from seeing any of the other GPs in the practice.

You do not need to take any further action, but if you have any questions, or wish to discuss this further with us, please contact the surgery you are registered with (number at the top of this letter).

Thank you.

Yours faithfully

THE COPPICE SURGERY & ANGMERING MEDICAL CENTRE

Please ensure you complete and sign all the forms in the pack as we may not be able to register you without signatures.

The Coppice and Angmering Medical Centre

Online Services Records Access

Patient information leaflet ‘It’s your choice’

If you wish to, you can now use the internet 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.
Being able to see your record online might help you to manage your medical conditions. It also means that you can even access it from anywhere in the world should you require medical treatment on holiday. If you decide not to join or wish to withdraw, this is your choice and practice staff will continue to treat you in the same way as before. This decision will not affect the quality of your care.
You will be given login details, so you will need to think of a password which is unique to you. This will ensure that only you are able to access your record – unless you choose to share your details with a family member or carer.
The practice has the right to remove online access to services. This is rarely necessary but may be the best option if you do not use them responsibly or if there is evidence that access may be harmful to you. This may occur if someone else is forcing you to give them access to your record or if the record may contain something that may be upsetting or harmful to you. The practice will explain the reason for withdrawing access to you and will re-instate access as quickly as possible.

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 can’t 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.
The information that you can see online may be misleading if you rely on it alone to complete insurance, employment or legal reports or forms.
Be careful that nobody can see your records on screen when you are using Patient Online and be especially careful if you use a public computer to shut down the browser and switch off the computer after you have finished.

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.

Things to consider

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. This may occur before you have spoken to your doctor or while the surgery is closed and you cannot contact them. If this happens please contact your surgery as soon as possible. The practice may set your record so that certain details are not displayed online. For example, they may do this with test results that you might find worrying until they have had an opportunity to discuss the information with you.
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. If it would be helpful to you, you can ask the practice to provide another set of login details to your Online services for another person to act on your behalf. They would be able to book appointments or order repeat prescriptions. They may be able to see your record to help with your healthcare if you wish. Tell your practice what access you would like them to have.
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.
More information

For more information about keeping your healthcare records safe and secure, you will find a helpful leaflet produced by the NHS in conjunction with the British Computer Society:
Keeping your online health and social care records safe and secure

The Coppice and Angmering Medical Centre

Patient Online: Registration formAccess to GP online services

Surname
First name
Date of birth
Address
Postcode
Email address
Telephone number / Mobile number

I wish to have access to the following online services (tick all that apply): If you require access to requesting prescriptions and accessing medical records, you will be required to provide 2 forms of identification. 1 photo ID, 1 proof of address, with this completed form.

Booking appointments

/ 

Requesting repeat prescriptions

/ 

Accessing my summary medical record

/ 

Access to my Detailed Coded Record

/ 

If you have said yes to number 4 and you are a new patient then please note that online access can take up to 3 months before it will be available as we will need to make sure your records are accurate and up to date.

Access to my medical record declaration

I wish to access my medical record online and understand and agree with each statement (please tick)

I have read and understood the information leaflet provided by the practice

/ 

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

/ 

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

/ 

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

/ 

If I see information in my record that it not about me, or is inaccurate I will log out immediately and contact the practice as soon as possible

/ 
Signature / Date

For practice use only

Identity verified through
(tick all that apply) / Photo ID 
Proof of residence 
Vouching 
Name of person vouching…………… / Name of verifier / Date
Date account created
Date logon details sent
Approved by:

If you require access to another person’s online records please ask for a Proxy form.

The Coppice and Angmering Medical Centre.

Consent to Share Records

If you are filling out this form on behalf of another person or child, the practice will consider this request. Please ensure you fill out their details in section A and your details in section B, and complete in BLOCK CAPITALS.

______

A. Please complete the following for the patient wishing to give consent/dissent.

Forename(s) / Surname
Address
Postcode / Phone Number
Date of Birth / NHS Number (if known)

B. If you are NOT the person named in section A, please complete this section.

Your Name
Date of Birth
Relationship to Patient

C. How the NHS will use your Data

The following questions allow you to tell us how you would like The Coppice and Angmering Medical Centreto share your medical records with other NHS organisations. Any previous sharing preferences you have given will remain in place. If you have not expressed a preference previously, the default options as given below will be applied.

Do you consent to The Coppice and Angmering Medical Centresharing your medical records with other NHS organisations with whom you may register in the future for the purposes of your healthcare? This is known as sharing out.
Default setting: NO / YES ☐
NO ☐
Do you consent to The Coppice and Angmering Medical Centreviewing the medical records shared by other NHS organisations with whom you may register in the future for the purposes of your healthcare? This is known as sharing in.
Default setting: NO / YES ☐
NO ☐
Do you consent to The Coppice and Angmering Medical Centresharing information about your medication and allergies with Secondary Care services (hospitals), for the purposes of healthcare? This is known as a Summary Care Record.
Default setting: YES / YES ☐
NO ☐
Your signature
Date

THE COPPICE SURGERY/ANGMERING MEDICAL CENTRE

NEW PATIENT QUESTIONNAIRE – ADULT

Please complete ALL the relevant questions. The information will help the practice to provide better medical care for you.

Name……………………………………………. Date of Birth…………………..

Please tick preferred contact number.

Home no:…………………...Mobile No:…………………….. E-Mail…...……………..………….

Height………………… Weight……………. Occupation……………………

Ethnicity………………………………………

Place of Birth……………………………………..

Next of Kin (Relationship)…………………………….Next of Kin ………………………….

Contact Number (Next of Kin)……………………………………… Tick if their registered at this practice

Are you a registered carer? YES/NO

Name of person you care for………………………………………………………..

Do you have a carer?

Name of carer………………………………… Contact number of carer………………………………..

Are you registered as Housebound? Do you live in a Nursing Home?

Are you registered blind or partially sighted? YES/NO

Are you registered deaf? YES/NO

Are you registered disabled? YES/NO

Please specify disability. ……………………………………………………………..

Do you suffer from any of the following?

Have you had a review in the last 12 months?

Heart DiseaseY/NY/N

StrokeY/NY/N

High Blood PressureY/NY/N

AsthmaY/NY/N

Diabetes:

Type 1Y/NY/N

Type 2Y/NY/N

Chronic Obstructive Airways DiseaseY/NY/N

EpilepsyY/NY/N

CancerY/N

If yes please specify type……………………………….…

Any other serious illnessY/N

…………………………………………………………………………..

Family History (Parents, Brothers and Sisters ONLY)

Do you have a family history of any of the following?

Heart AttacksY/N
StrokesY/N
Breast CancerY/N
Ovarian CancerY/N
Bowel CancerY/N
DiabetesY/N

If yes please give details including RELATIONSHIP, ILLNESS and AGE AT DIAGNOSIS.

………………………………………………………………………………………………………………………………………………………………………………………………………………………………………

Have you had any major operations or serious injuries?Y/N

If YES please give details including diagnosis, year and hospital attended.

……………………………………………………………………………

Smoking Status

Do you smoke YES / NO / EX-SMOKER

If so how many – tick relevant boxLess than 10

10 – 20

More than 20

If you would like support and advise to stop smoking - Please contact the Surgery and make an appointment with the Smoking cessation clinic.

If You are an Ex-Smoker what year did you stop?………

Alcohol Questionnaire

Questions / Scoring System
1 2 3 4 5 / Your score
How often do you have a drink that contains Alcohol? / Never / Monthly or less / 2-4 times per month / 2-3 times per week / 4+ times per week
How many standard alcoholic drinks do you have on a typical day when you are drinking? / 1-2 / 3-4 / 5-6 / 7-8 / 10+
How often do you have 6 or more standard drinks on one occasion? / Never / Less than monthly / Monthly / Weekly / Daily or almost daily

IF YOU SCORE 5 OR MORE PLEASE COMPLETE THE QUESTIONNAIRE ON THE NEXT PAGE

Alcohol Users Disorders Identification Test (AUDIT)

Questions / 0 / 1 / 2 / 3 / 4 / Your Score
How often in the last year have you found you were not able to stop drinking once you had started? / Never / Less than monthly / Monthly / Weekly / Daily or almost daily
How often in the last year have you failed to do what was expected of you because of drinking? / Never / Less than monthly / Monthly / Weekly / Daily or almost daily
How often in the last year have you needed an alcoholic drink in the morning to get you going? / Never / Less than monthly / Monthly / Weekly / Daily or almost daily
How often in the last year have you had a feeling of guilt or regret after drinking? / Never / Less than monthly / Monthly / Weekly / Daily or almost daily
How often in the last year have you not been able to remember what happened when drinking the night before? / Never / Less than monthly / Monthly / Weekly / Daily or almost daily
Have you or someone else been injured as a result of your drinking? / No / Yes, but not in the last year / Yes, during the last year
Has a relative/friend/doctor/health worker been concerned about your drinking or advised you to cut down? / No / Yes, but not in the last year / Yes, during the last year

Scoring: 0-7 = sensible drinking, 8 -15 = hazardous drinking, 16-19 = harmful drinking and 20+ = possible dependence

Pint of Regular Beer/Lager/Cider = 2 units

Alcopop or Can of Lager = 1.5 units

Glass of wine (175 ml) = 2 units

Single Measure of Spirits = 1 unit

Bottle of wine = 9 units

Allergies

Do you have any drug allergies? Yes / No

Do you have any other allergies?Yes / No

If YES please list …………………………………………………………………………………………………………………………………………………………

……………………………………………………………………………

Medication

Are you taking regular medication on a repeat basis?

Please state …………………………………………………………………………..

…………………………………………………………………………

ADDITIONAL INFORMATION …………………………………………………………………………………………

…………………………………………………………………………………………

*** If we consider that you may benefit from any health advice from our practice nurses, you will be invited for a brief discussion with one of them **

ACCESSIBLE INFORMATION STANDARD

For most of us our preferred method of contact is our home number or mobile number but, for example, if you suffer from hard of hearing or blindness that method may not be suitable for you. If you, or someone you are caring for, would prefer us to make contact in another way, please indicate your preference below. We will then record your preference by highlighting it on your medical records.

Do you have an impairment and would prefer practice communications via a specific method?

YES NO

If YES, please give details of your impairment below and your preferred method of communication:

Signature ………………………………………………….

Date………………..

WE WILL NEED :( before registration can take place)

PROOF OF ID ( passport, photo driving licence)
PROOF OF ADDRESS (A formal letter/ statement that has your current address on or address that you will be moving to)
VALID TELEPHONE NUMBER (also Mobile) for contact.

LEAVING MESSAGES

In accordance with the Data Protection Act, the Practice needs consent from any patient that has an answer phone and is happy for us to leave a message. If we do not have consent, we will be unable to leave a message on an answer phone or with a 3rd party.

Please complete the appropriate box:

I give consent for the Practice to leave messages on my answerphone

Telephone No……………………..and/or……………………..

*complete land line and/or mobile number as appropriate.

I do not give consent for the Practice to leave messages on my answer phone.

I give consent for the practice to send a SMS text message to my mobile phone, as a reminder of pre-booked appointments.

Mobile phone number………………………………………….

I do not give consent for the practice to send a SMS text message to my mobile phone.

This consent is to remain in force until further notice of cancellation by me.

Signed………………………………………………….

Print full name…………………………………………

Date of birth.__/__/____

For practice use only:

Identification checked by:…………………………………………….

Date:………………………………….