Somercotes Medical Centre

Somercotes Medical Centre

REGISTERING AS A PATIENT

Welcome to Somercotes Medical Centre

This practice accepts patients who have moved into, or are living in, our catchment area: - Somercotes, Swanwick, Alfreton, Riddings, Leabrooks, South Normanton, Ironville, Pyebridge and Jubilee.

Registration forms and proof of identity and address

To register as a patient you will need to complete this registration pack and also provide identification and evidence that you permanently live at an address in our practice area (See Pg. 3 for details of suitable documents). Individuals wishing to register with the practice temporarily, whilst away from their permanent UK address will also need to provide full details of their usual doctor and surgery. We may need to contact your usual doctor as part of any treatment we provide and we will need to forward details to them afterwards to keep your medical records up to date.

Please provide us with a daytime contact number in addition to your home phone number as there may be times when we need to make contact with you promptly during opening hours. It is important that changes to your personal details such as name, address and contact numbers are updated promptly.

We ask patients who have regular medication to make a routine appointment with a GP shortly after they register with us. All patients are encouraged to attend the surgery for a health screen with one of the nursing team.

If you move to an address outside the practice boundary you will need to register with a practice more local to your new address. Unfortunately it is not practical for our medical team to continue to provide care for you when you live outside the practice boundary.

Named GP

All NHS patients are required to have a named GP. Your named GP at this surgery is Dr Elise MacLachlan. This just means that she has responsibility for your overall care; you can still see any doctor at the surgery.

Entitlement to NHS Treatment

Please note that this practice, and all Derbyshire practices, strictly adheres to the following guidance:

Entitlement to free NHS treatment is in the basis of residency regardless of any previous national insurance or tax contributions and irrespective of whether you are a UK passport holder. Holding an NHS number does not indicate that NHS treatment is free of charge. Proof or identity and address are required (as described above).

UK residents:

If you have established a main residence within our practice area, you are entitled to request to be permanently registered with the practice.

UK citizens living abroad:

If you live abroad for most of the year you are not entitled to continue to be registered with this practice. Anyone leaving the UK with the intention of living abroad for a period of 90 days or longer must notify the practice in advance. If you fall ill when returning on a visit you are entitled to emergency care, if this is deemed necessary by the Practice. Please also see below to see if you are resident in an EEA country.

Insured EEA residents:

If you do not have a main residence within our practice area you are entitled to ‘any necessary care’ for chronic conditions including routine monitoring of existing conditions. This includes the following types of healthcare services for ongoing conditions – blood tests, blood pressure checks, routine maternity care, oxygen, dialysis and warfarin tests. Visitors will need to produce their European Health Insurance Card.

Overseas visitors (not EEA Residents):

If you do not have a main residence within our practice area you do not qualify for free treatment and cannot register with the practice as an NHS patient. The only exception to this is if you need emergency or immediately necessary treatment, which will be provided free of charge. The GP will decide if your condition falls into this category. You may always, however, be treated as a private patient.

EEA Member States are:

Austria, Belgium, Bulgaria, Cyprus, Czech Republic, Denmark, Estonia, Finland, France, Germany, Greece, Hungary, Iceland, Italy, Latvia, Liechtenstein, Lithuania, Luxembourg, Malta, Netherlands, Norway, Poland, Portugal, republic of Ireland, Romania, Slovakia, Slovenia, Spain and Sweden. Switzerland also qualifies under the Insured EEA Residents category.

Registered Asylum Seekers:

Are entitled to free NHS services, subject to production of evidence, for the entire term of the application process, including any appeals. Any person who has achieved refugee status is also entitled.

Name Identification / Address Identification
§  Current signed full passport
§  Current UK driving licence
§  Blue disabled drivers pass
§  Current benefit or State Pension notification letter confirming rights to benefits for the current period.
§  Current HMRC tax notification e.g. PAYE coding, statement of account (P45’s & P60’s are not official HMRC documents).
§  Shotgun or Firearms Certificate.
§  Travel documents issued to foreign nationals granted permission to remain in the UK.
§  Current EU/EEA driving licence.
§  Residence permit issued by the Home Office to EU nationals.
§  EU/EEA member state identity card. / §  Recent utility bill or statement showing current address in our practice area.
§  Local Authority tax bill for current year.
§  Bank or Building society statement.
§  Credit/Store card statement.
§  Mortgage statement.
§  Local Council rent card.
§  Tenancy agreement.
§  Solicitor’s letter confirming the recent purchase of your property.

Under 16’s

Children under the age of 16 who’s Parent/Guardian is registered with the practice/registering at the same time will need to provide either:

§  Original Birth Certificate or a certified copy.

§  Passport.

If you are unable to provide any of the above documents please speak to a member of the reception team who will be able to discuss alternative documents.

Somercotes Medical Centre

Contact Information

Full name
Address
Postcode
Date of Birth
Home tel. No.
Mobile tel. No.
Email address

Please note that we would like to use your mobile phone number to send out text messages concerning your appointment reminders and any test results you may have.

Are you happy for the surgery to do this? Yes/No

The surgery offers online access which allows you to book and cancel appointments, order and view repeat medications and update your patient information.

Would you like access to these services? Yes/No

The NHS would like to hold limited information about you on the Summary Care Record. The reason for doing this is to have details of your current medication and allergies available to NHS staff treating you in the case of an emergency. The only people who can see the information will be healthcare staffdirectly involved in your care who have a special smartcard and access number (like a chip-and-pin credit card).

Are you happy for the NHS to hold a summary care record for you?

Yes I consent to the NHS holding a summary care record / No I do not consent to the NHS holding a summary care record. (Please delete as appropriate)

Your signature

Date

Somercotes Medical Centre

Registration Information - Ethnicity and Language

Please complete the form for each member of the family.

Parents or guardians please complete this for your children. Thank you.

Your full name:

(or your child’s name if completing on their behalf)

✓Please tick your ethnic category:

British (white) Bangladeshi (Asian or Asian British)

Irish (white) Any Other Asian Background (Asian or Asian British)

Any Other White Background Caribbean (Black or Black British)

White and Black Caribbean (Mixed) African (Black or Black British)

White and Black African (Mixed) Any other Black Background (Black or Black British)

White and Asian (mixed) Chinese (Other Ethnic Groups)

Any Other Mixed Background (Mixed) Any Other Ethnic Group

Indian (Asian or Asian British) Not Stated

Pakistani (Asian or Asian British)

If other please state:

✓Please tick your preferred language:

Arabic Italian Somali

Bengali Japanese Spanish

British Sign Language Kurdish Swahili

Chinese Yue Makaton Tamil

English Mandarin Chinese Turkish

Parsi Patois/Creole Urdu

French Polish Vietnamese

German Portuguese Welsh

Greek Punjabi

Gujerati Russian

Non-verbal communication

Any other language

If other languages please state:

The ethnic category and languages used above are as defined by and collected at the request of the Department of Health and are assured by the Information Standards Board for Health and Social Care.

Somercotes Medical Centre

Adults New Patient Health Questionnaire

To register with the Practice please complete the following questionnaire as fully as possible. Please then return it to the practice. Your answers will be treated in the strictest confidence but will allow us to endure continuity of health care until your medical records arrive from your previous surgery.

Full Name: …………………………………………………………. Date of Birth: ………………………

Your Health

Your Height:
Your Weight:
Your Blood Pressure
It is recommended that you have your BP checked every 5 yrs if you are aged over 45.

Do you suffer or have you suffered from any of the following conditions?

Please tick as appropriate Yes No

Asthma,COPD
Diabetes
Epilepsy
Thyroid Problems
Stroke
Mental Health Problems
Heart Disease/Attack
Cancer
High Blood Pressure

Is there a family history of any of the following conditions (in a first degree relative i.e. your mother, father, brother or sister)?

Asthma,COPD
Diabetes
Epilepsy
Thyroid Problems
Stroke
Mental Health Problems
Heart Disease/Attack
Cancer
High Blood Pressure

Do you suffer from any of the following difficulties: Yes No

Visual (i.e. registered blind)
Hearing (i.e. wear a hearing aid)
Mobility (i.e. use a walking stick/wheelchair/housebound)
Learning (i.e. have a permanent carer)

Do you suffer from any allergies? Yes No

If yes please specify:

Questions for Women only

Have you ever had a smear?
If yes, what was the date of your last smear?
Do you have a coil fitted?
If so when was your last coil check?
Have you had a hysterectomy?

Please complete the following sections about lifestyle. You’re answers will help us provide you with the most appropriate advice and ongoing health care.

Alcohol Consumption

Drink / Pint of regular beer/cider / Alcopop or can of lager / Glass of wine
175ml / Single measure of spirits / Bottle of wine
Units / 2 units / 1.5 units / 2 units / 1 unit / 9 units

How many unit’s do you drink a week?

Questions / 0 / 1 / 2 / 3 / 4
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 units do you have on a typical day when drinking? / 1-2 / 3-4 / 5-6 / 7-9 / 10+
How often do you have 6 or more units on one occasion? / Never / Less than monthly / Monthly / Weekly / Daily or almost daily

Smoking

I have never smoked

I used to smoke ……………Cigarettes/cigars a day ……………………oz. tobacco a day

Year started …………………………..Year stopped ………………………….

I currently smoke ……………Cigarettes/cigars a day…………………….oz. tobacco a day

Year started…………………………….

Do you want to stop smoking? Yes/No

Giving up smoking will greatly benefit your health. We have a smoking cessation advisor in surgery that would be happy to support you when you decide to quit. In addition you are able to access the Derbyshire County Stop Smoking Service on 0800 085 22 99 / 01246 515153

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