Doctors: O’Flanagan, Smith, Rashid & Atxa

The Saltscar Surgery • 22 Kirkleatham Street • Redcar • TS10 1UA

Tel: (01642) 471388 • Fax: (01642) 511480 • Web:

UNDER 16New Registration Questionnaire

Failure to complete may result in non-registration.

Today’s Date:______

Full Name: ______Date of Birth ______

Address: ______

Telephone Number: (Must Complete) ______

Mobile Number:______

You will be signed up to the surgeries text messaging service and automatic voice activated service for reminders about appointments and other services the surgery may offer from time to time

If you consent to the above please sign here: ______

If you decline to the above please sign here: ______

Ethnic Origin: Please Tick One:

White British
White Irish
Other White Background
Black Or Black British Caribbean
Black Or Black British African
Other Black Background
Asian or Asian British Indian
Asian or Asian British Pakistani
Asian or Asian Bangladeshi
Asian or Asian Chinese
Other Asian Background
Mixed White and Black Caribbean
Mixed White and Black African
Mixed White and Asian
Other Mixed Background
Other Ethnic Background

Main Language Spoken______2nd Language ______

Height: ______Weight______

We would like to know if you have any communication needs due to a disability or sensory loss, where you may require information in a different format or require communication support. For example: You may need information in braille or use British Sign Language to communicate. Please tell us below:

______

______

Next Of Kin Details:

Full Name:______

Relationship :______(i.e mother/father/spouse)

Address:______

Telephone Number: ______

Do you have a Carer? YES/NO (If so please give details)

Name: ______

Address______

Are you the carer for somebody else? YES/NO (If so please give details)

Name: ______

Address:______

Do you suffer from any medical Condition? E.g. Heart disease, high/low blood pressure, Diabetes, Asthma, Arthritis Etc.

______

Have you had operations or investigations in the past? If so please give approximate dates and details.

______

Are You currently under the care of the hospital? If so please give details:

PLEASE REMEMBER TO CONTACT THE HOSPITAL TO INFORM THEM OF YOUR NEW GP.

Please list the names and dosage of your current medication (if any)

______
______

Do you have any Allergies, if so please give details:

______
Has your mother, father, brother or sister suffered from any of the following? Please circle yes or no.

Heart disease blow the age of 60 YES/NOStroke YES/NO

Asthma YES/NOHigh blood pressure YES/NODiabetes YES/NO

Glaucoma YES/NO

Have you any other medical or social concerns of which you might wish us to be aware of?

______

IMPORTANT INFORMATION REGARDING YOUR RECORDS PLEASE READ AND ASK FOR HELP FROM STAFF IF REQUIRED.

Do you give permission for the surgery to share your information with other HEALTHCARE Providers – when you visit them to be seen?

Please READ the attached leaflet*

*leaflet Name - Your Electronic Health Record

Option 1
After reading the above leaflet I am happy for my full patient record to be viewed by health and care organisations involved in my carewithout the need for an extra verification step.
Signature: ______Date______
Option 2
After reading the above leaflet I DO NOT want my patient data to be viewed by otherhealth and care organisations involved in my care.
Signature: ______Date______
Option 3
I would like to provide an extra security code, or online approval to the health and care organisations involved in my care in order to view my record.
For this step to work, you must keep you mobile number / email address up to date or have access to your GP online account. Please ensure you have access or you keep the practice up to date with your contact details.
Signature: ______Date______

Name & Relationship of Signatory : ______

Patient Name…………………………………………..

Date of Birth…………………………………………….

NHS Number (if known)……………………………….

(Name of Surgery) 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.

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. You can refuse if you think access is unnecessary.

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 do is write to your Surgery informing them of your decision to “Opt-out”, or print off the “Opt-out” form from the website and take or post it to your Surgery. If you wish to “Opt-out” now, follow the same process. 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.

Please tick the box if you do not wish to have a Summary Care Record:

No I would not like to have a Summary Care Record

HealthSpace information

In addition, patients over 16 can register on a secure website called HealthSpace for a ‘Basic’ account which gives you access to a Personal Health Organiser. Register at to do this. If you go a stage further you can register for an ‘Advanced’ account which will entitle you to see a copy of your Summary Care Record once it has been created. Complete the Advanced Registration application and print off the form and contact your PALs office to find out where you should go to register for an Advanced HealthSpace Account, by telephoning …………….. When you register you must remember to bring along with you 3 items of identification, Passport or Driving Licence and 2 Utility Bills within the last 3 months.

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