Welcome to New Pond Row Surgery

To help us get to know you better, we ask that you complete the following questionnaire. We want to assure you that we treat your information with care and that your records remain confidential at all times.

It is really important that you answer as many questions as you can / that are relevant to you. We have provided guidance for some questions (marked with a *) at the end of the survey in the NOTES section. Please read the notes.We may not be able to register you if we do not have enough information from you.

Office use: Formal ID seen and scanned (date stamp) / Read Code: 9RN
About you: / Title / First name / Middle names / Surname
Your Name
Preferred name / (if different from your given name)
Previous last name/s / (if applicable)
Sex*1 / Date of birth / / / / Birth country / (e.g. England)
NHS Number*2 / Place of birth / (e.g. Worthing)
Your marital status*3 / (e.g. prefer not to say
married, single, civil partnership) / Nationality / (e.g. British)
Sexual orientation*4 / (e.g. prefer not to say, straight,gay …) / Ethnicity*6 / (e.g. Black)
Gender identity*5 / Culture*6 / (e.g. Caribbean)
Main spoken language / Religion*7 / (e.g. No beliefs, Christian, Muslim)
Do you need an interpreter / (or assistance with communicating?)
Help with correspondence / (Large print / Braille?)
If you are not native British, date you first came to UK? / / /
If you are returning from Abroad: / Date you left UK / / /
From where: / Date you entered UK / / /
If you are ex-Military / Which service / (e.g. Army, Navy, Air Force …)
Date of Enlisting / / / / Service Number
Date of Leaving / / / / or Personnel No.
Yourcurrent home address / Yourprevioushome address
Line 1 / Line 1
Line 2 / Line 2
Line 3 / Line 3
Line 4 / Line 4
TOWN / TOWN
County / County
Post Code / Post Code
Please provide any special instructions for access (Key safe / door access codes etc.?)
To help us with home or emergency visit instructions, please tell us a bit more about your home. (e.g. detached / terraced / bungalow / upstairs flat / mobile home / caravan / Other …)
Contacting you / Permissions to contact you*8
Home Phone
Others may hear messages about results /  YES – Answer Phone Messages
 YES – Messages about Results
Work Phone
Personal Mobile Phone
Others may see results if joint account /  YES – Receive Texts
 YES – Texts about Results
Your Personal Email
Others may seeresults if joint account /  YES – Receive Emails
 YES – Emails about Results
Facetime / Skype ID
Your previous GP
Your previous GPSurgery address / If ex-Military,address before enlisting. If from abroad, UK address where you Registered with a GP
GP’s name / Dr
Surgery name
Line 1 / Line 1
Line 2 / Line 2
Line 3 / Line 3
Line 4 / Line 4
TOWN / TOWN
County / County
POST CODE / POST CODE
ONLINE Patient Services (via a Secure clinical system called EMIS Patient Access)
Once this form has had all its data entered on to the computer we will be able to provide you with access to online services. If you tick yes to any of the below we will create a letter with instructions and passwords to help you register yourself online. We will leave this letter ready for your collection at the reception desk. Please allow 14 working days from the date that you leave this form with us.
Online Access to: / Yes / No / Yes / No
Book appointments / View my medical record
Repeat Prescriptions / Update contact details
About your life - work
To help us get to know you, please can you let us know a little about your life at home
Please answer only those questions which are relevant to you.
Please select which of the following is / are most appropriate for you (write yes)
Employed / Self Employed / and Full-time / and Part-time
Recently Retired / and was Full-time / and was Part-time
Your current occupation (or if ‘Retired’, your previous occupation)
Not currently employed and
Seeking work / Not seeking work / Retired
About your life at home – family
How many children do you have? / If female, number of births
If you have a child / some children / if female, those children to whom you gave birth mark (x)
His / Her / Their First Name/s + Surname/s / Date/s of birth / Live with you? / X
/ /
/ /
/ /
/ /
Your ‘next of kin’
Title / Home Phone
Forename / Mobile
Surname / Address
Relationship
Your ‘emergency contact’ - If they are your next of kin, write SAME AS ABOVE
Title / Home Phone
Forename / Mobile
Surname / Address
Relationship
Your Key Contact(Partner / Family member / Friend)
Title / Home Phone
Forename / Mobile
Surname / Address
Relationship
Power of Attorney Regarding Your Health and Welfare
If you have arranged a Power of Attorney with a lawyer we will need to see the original copy of all the information at the surgery for our records. Please write YES if you have any of the following…
Enduring Power / If yes, please bring to surgery
Lasting Power Personal Welfare / If yes, please bring to surgery
Title / Home Phone
Forename / Mobile
Surname / Address
Relationship
Care Organisation Provider (if you have one)
Organisation name
Key Contact & Their Role
Contact number
What do they provide?
What sort of support and how often?
Do you pay them directly? / (Or is this funded by others?)
We can help you with access to various services depending upon your personal situation
Communication
Any other help you feel you may need or information you would like us to be aware of communicating with us or other professionals? (Please provide some details)
For example, translator for language, hearing aid if you have some deafness?
NHS Organ Donor Registration*9 (extra signature needed at the end of the form)
I want to register my details on the NHS Organ Donor Register as someone whose organs/tissue may be used for transplantation after my death. Please write YES in the boxes that apply to you
ANY of my organs or tissues / OR select from following
Kidneys / Heart / Liver / Corneas / Lungs / Pancreas
NHS Blood Donor Registration*10 (extra signature needed at the end of the form)
I would like to join the NHS Blood Donor Register / (write yes)
Write YES if you have given blood in the last 3 years / (write yes)
Care
Are you a carer? / Do you have a carer?
If yes to either of the above please provide further details on our Carers Form.
Your consents for us to support your care …
You do not have to tick yes to any of the options if you do not want to.You can change your mind at any time about any of the options, but you will need to let us know.
Permission for us to leave atelephone message / let someone know you are in the surgery
If you would like New Pond Row Surgery to be able to leave messages about you with a particular person or allow us to tell that person whether or not you are currently in the surgery then please tick the relevant box/es in the section ‘Leave brief message about me with …’ below. Though we will be discreet, it is important that you understand that any medical contact involves sensitive personal information about you. If you have any concerns, please contact the surgery and do not sign this form until you are completely sure.
Permission for us to talk with specific people about you and your medical information
If you would like to nominate relatives, carers or friends to have access on your behalf to your medical records please tick the relevant box/es in the ‘Share Information in my medical records with …’ section below. To protect your interests, it is important that you understand what you are potentially providing permission for the individual to be able to …
1)Talk with a Clinician (GP or Nurse) about you and your records
2)Have access to the lists of medications that you have
3)Have access to information in your medical records
4)Order your repeat medications for you
5)Book and change appointments on your behalf
6)Have access to your test results if they ask
This is all sensitive personal information about you. Unfortunately, there is no way in our system to only give access to part of your information. It is all or nothing. If you have any concerns, please contact the surgery and do not sign this form until you are completely sure.I agree that New Pond Row Surgery can ….
Leave brief messages about me with… / Yes / No / N/A
My Carer
My Next of Kin
My Emergency Contact
My Key Contact
Other…
Share information in my medical records with… / Yes / No / N/A
My Carer
My Next of Kin
My Emergency Contact
My Key Contact
Other …
Your Agreement/s
Your Signatures / Signed / Dated
I have read the notes and understand the services and consents that I have indicated. / dd / mm / yyyy
I confirm that my personal information is correct / / /
IF applicable, to your answers above:
I wish to register with NHS Organ Donation (1) / / /
I wish to register for NHS Blood Donation (2) / / /
Summary Care Records
.
The Summary Care Record provides key information about your care record to colleagues in emergency situations, such as Accident and Emergency Departments. The Practice computer system is able to update a summary of your medical record onto a secure central NHS database that can only be accessed with your permission by healthcare professionals in other locations. The NHS assumes that patients wish to have this function provided to support their care. We are able to stop your record from being a part of this scheme by adding a code to your record. However please note,IF YOU SAY NO - NHS healthcare staff caring for youmay not be aware of your currentmedications, allergies you suffer fromand any bad reactions to medicinesyou have had, in order to treat yousafely in an emergency. If you have any questions, or if you want to discuss your choices, please: • phone the Summary Care Record Information Line on 0300 123 3020; • contact your local Health watch 0300 012 0122
I do NOT want a Summary Care Record / / /
NOTES
Some of the questions on this form are very personal. We ask them to help us get to know you better and to try to provide a more sensitive and personal service as we value equality and diversity.
You will see that there is the option to ‘prefer not to say’ ( = leave blank) for questions on
Marital Status, Sexual Orientation, Gender Identity and Religion
1 / Sex –Answer examples
Male / Female / Intersex / Other
2 / NHS Number
If you have this it helps us linking to the records at your previous surgery (where applicable)
We may require this if you are unable to provide us with sufficient other identification
3 / Marital / Personal Status - Examples
Prefer not to say, Single, Divorced, Widowed, Married, Civil Partnership, Living with Partner, Other …
4 / Sexual Orientation –Examples
Prefer not to say, Straight, Heterosexual, Gay, Homosexual, Lesbian, Bisexual, Asexual, Other…
5 / Gender Identity - Examples
Prefer not to say, Male, Female, Transgender, Third Gender, Genderless, Trans Man, Trans Woman, Other …
6 / Ethnicity and Cultural Background- Examples
E.g. Ethnicity / Race = White
E.g. Cultural Background = British
E.g. Ethnicity / Race = Black
E.g. Cultural Background = African / White, British
White,Irish
Black, African
White, French / Asian, Indian
Asian, Chinese
Mixed White, British Asian
Mixed Black, British African
7 / Religion - Examples
Prefer not to say, No Beliefs, Atheist, Christian, Jehovah’s Witness, Muslim, Jewish …..
8 / Contacts
We provide an SMS service via the NHS secure email system to send you a text when you book an appointment. We may also use SMS text to advise patients regarding the opportunity to access certain services or to let them know that results have been received.
We are also able to send occasional newsletters by email or advisement that patients are able to access certain services such as vaccination clinics.
You can opt out of receiving emails and or texts by contacting reception.
New Pond Row Surgery will not pass on your details to anyone else
We strongly recommend that you use a personal rather than a joint email account
e.g. is better than
9 / For more information about NHS organ donation, or call 0300 123 23 23
10 / For more information regarding NHS blood donation, or call 0300 123 23 23

CQC | NPR | New Patient Registration Form – July 2016