Dr. Aileen Robertson
Dr. Cibi Mukundan
Dr. Narayanan Annamalai
Dr. Navjeet Dua
Dr. Shehzad Ali
Dr. Andre Krzeminski
Dr. Rita Nwafor
Max Hand (Manager)
Dear new patient
Thank you for expressing an interest in registering as a patient with us. Attached with this letter is a welcome pack.
Your welcome pack includes:
· New Patient Registration forms - You must complete a registration form for each person registering.
· GMS 1 Family doctor services registration form – also one for each family member. Please do complete with care - we can’t register you if any information is missing.
Please remember that you can find much more detail about us and about the services we offer on our website: www.albanyhousemedicalcentre.co.uk
Yours sincerely
Max Hand
Business manager
Checklist
Have you signed and dated the mauve GMS 1 family doctor services registration form?
Have you answered ALL the questions on the Patient Registration form?
Do you have proof of identity for us to check?
1) Passport/photo driving licence/birth certificate
2) Proof of address (bank statement, utility bill (not mobile phone), mortgage statement, council tax
Albany House Medical Centre /New Patient Registration - Albany House Medical Centre
3 Queen Street, Wellingborough, NN8 4RW
(Visits 01933 234905 (08:00 to 18:30) Appointments: 01933 234900 (08:30 to 18:00). Enquiries: 01933 234900 (10:30 – 15:30). www.albanyhousemedicalcentre.co.uk
Please complete this confidential questionnaire (one for each adult member of the family to be registered).
PLEASE WRITE CLEARLY!
Personal information:
Full name: …………………………………………… Date of birth: ………………………..………………………
Your height:
FT/Inches: …………….………..CMs: ……………………….. / Your weight:
Stones/Lbs: ……….….……… or KGs: ……….……………
Home phone: ………………………………….. Mobile: ……………………………. Work: ………………………….
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Smoking and alcohol consumption:
Are you a smoker? YES/NO / If so, how many do you smoke a day? / Have you ever been a smoker? YES/NOIf you smoke and would like help to stop, please ask about our smoking cessation clinics. If you smoke and do not wish to stop at this time, please read and then sign the following statement:
“I am aware that smoking is bad for my health, but I do not wish to receive smoking cessation advice at this time”.
Signed: ………………………………… / Date: ………………….
Alcohol consumption - For the following questions please circle the answer that best applies.
One unit of alcohol is ½ pint average strength beer/lager OR a small glass of wine OR one single measure of spirits. Note that a high strength beer/lager may contain 3-4 units.
MEN AND WOMEN: On average how many units of alcohol do you consume each week?
MEN: How often do you have Eight or more units on one occasion?
WOMEN: How often do you have SIX or more units on one occasion?
Never / Less than monthly / Monthly / Weekly / Daily or almost daily
If the above answer is never you need not answer the following questions about alcohol consumption.
How often in the last year have you been unable to remember what happened the night before because you had been drinking?
Never / Less than monthly / Monthly / Weekly / Daily or almost daily
How often in the last year have you failed to do what was normally expected of you because of drinking?
Never / Less than monthly / Monthly / Weekly / Daily or almost daily
In the last year has a relative or friend, or a doctor or other health worker been concerned about your drinking and suggested you cut down?
No / Yes, on one occasion / Yes, on more than one occasion
If you want support or advice about your consumption of alcohol, contact Drinkline on 0800 917 82 82 or contact us for a referral to a specialist agency.
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Your religion:
5No religion / 5Church of England / 5Catholic / 5Other christian (Specify):5Buddhist / 5Hindu / 5Jewish / 5Jehovah’s witness / 5Muslim / 5Sikh
5Other religion not listed above (Specify)
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Your ethnic origin (select one):
5White (UK) / 5White (Irish) / 5White (Other) / 5 Asian5 Indian/Brit. Indian / 5Chinese / 5Pakistani/British Pakistani / 5Bangladeshi/British Bangladeshi
5Other Asian background / 5African / 5Caribbean / 5 Other black background
5Other mixed background / 5Ethnic category not stated / 5Other
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Your main or first language spoken / understood (select one):
5 English / 5 Hindi / 5 Gujurati / 5 Urdu5 Bengali/Sylheti / 5 Punjabi / 5 Polish / 5 Ukrainian
Other (please specify):
Will you require an interpreter to be booked when you visit the surgery? YES/NO
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Family history:
Is there a family history of any of the following? (Tick box) / Relationship – mother, father, son, daughter etc5 Heart disease (eg Angina or Heart Attack) - Diagnosed before age 60 5 After age 60 5
5 Stroke
5 Diabetes
5 Asthma
5 Hypertension
5 Epilepsy
5 Thalassaemia
5 Sickle cell
5 Cancer - Please indicate site (eg Breast, Prostate, Ovarian, Bowel). Site:
If you have Asthma:
In the last month, have you had difficulty sleeping due to your Asthma symptoms (including coughing)? YES / NO
Have you had your usual Asthma symptoms (cough/wheeze/chest tightness/shortness of breath during the day? YES / NO
Has your Asthma interfered with your usual daily activities (Housework/school/work) YES /NO
Medical background - Current medication
We need to know if you are currently taking any medication. Please bring the list of repeat medication attached to your last prescription (we will take a copy and return it to you) or list your repeat medication below. If none, state none..
Details of any allergies (food/medicine etc).
Please specify below. If none, state none.
Details of any problems administering medication
For example, swallowing difficulties or opening containers. If none, state none
Special needs
If you have any other special needs not described elsewhere on this form, please describe below. For example,
cultural/religious needs, assistance dogs, speech, sight or hearing impediments, mobility, etc. If none, state none
Medical background – Current problems
We also need to know about any current medical problems you may have. Would you please briefly describe these below.Continue on a separate sheet if you need to. If none, state none.
Summary care record
For more information see: www.nhscarerecords.nhs.uk
If you do not wish to have a Summary Care Record (SCR) automatically created for you tick here
You may elect to add additional information to your SCR by ticking here
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Electronic prescriptions
For more information see: http://www.connectingforhealth.nhs.uk/systemsandservices/eps/patients
From September 2013, we will be able to send a prescription electronically to the pharmacy of your choice. We are encouraging our patients to consent to having their prescriptions sent electronically to their preferred pharmacy. If you prefer a paper prescription and do not wish to have your prescriptions sent electronically, please tick here . For more information about electronic prescriptions, see our website.
Choice of pharmacy
Which pharmacy would you prefer to use to collect a prescription or have your electronic prescription sent to? Tick one.
Pharmacies are listed in distance from Albany House order (closest first).
3Q 5 Cohens (Herriotts Lane) 5 Cohen’s (Mannock) 5 Cohen’s (Gold street) 5 Superdrug 5 Boots 5 Co-op 5 Tesco 5 Berrymoor 5 Lloyds 5 Rowlands 5 Redwell 5 Croyland (Wollaston) 5
For more distant pharmacies, see NHS Choices (www.nhs.uk)
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Do you care for someone or does someone look after you:
If you are a carer, who do you care for (name/address/phone number)If you have a carer, please tell us who they are (name/address/phone number):
If you have a carer, please sign here if you wish us to disclose information about your health to your carer. If you would like to restrict what your carer can be told (for example test results only), please describe below. / Sign: / Date:
Our website contains a wealth of information about caring and support services available to carers
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Military service personnel only:
Your service no.: / Enlistment date: / Do you have any condition that entitles you to NHS priority treatment: Yes / NoPlease complete carefully - to register you must complete all sections of this form correctly. If you do not complete the form correctly, your registration will not be accepted.
For more information about the services we offer, please pick up a patient leaflet or see our website: www.albanyhousemedicalcentre.co.uk.
Online services registration (for appointment booking, repeat medication orders and other services)
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Please complete ONE form for each person wishing to register - things to note:
1) Registration of children under 16 – We regret that we are following guidance from the Royal College of General Practitioners that practices should not, for reasons of confidentiality, register under 16s to use online services.
2) Proxy accounts – in some cases it may be more suitable that someone else has access to online services – for example a carer, relative or friend – on behalf of a patient. Whoever holds the patient’s proxy does not need to be a patient of this practice but they must have a NHS number. In this case the proxy account holder must provide proof of identity. Note that the written consent of the patient is required for proxy access. We do not accept proxy access by parents for children under 16
3) You must specify what access is required. By default we assume that will require access for ordering repeat medication and booking GP appointments. But you can also have access to your shared care record, either at a summary or detailed level. You must tell us which level of access you require (ie summary or detail). If you leave that part of the form blank, you will only be able to use medication ordering and GP appointment booking.
4) Identity verification – you must provide any one of the following documents: passport, driving licence, a bank statement, utility bill, birth or marriage certificate. A photocopy is acceptable – please DO NOT SEND ORIGINAL DOCUMENTS BY POST because we will not be able to return them. You may send a photocopy but we will not return the copy to you.
Details of the PATIENT to be registered for online services:
Full name: ……………………………………………..
Date of birth: …………………………………………
Address: ……………………………………………………………………………………………
………………………………………………………………………………………………………..
Landline: ………………………. Mobile: ……………………… Email: ……………………………………………….
If another person is to access the patient’s record on their behalf (ie a PROXY ACCOUNT) details of the person holding the proxy (you must complete the patient details above as well):
Full name: ………………………………………………………………………………………………….
Date of birth: …………………………………………
Address: ……………………………………………………………………………………………
………………………………………………………………………………………………………..
Landline: ………………………. Mobile: ……………………… Email: ……………………………………………….
Relationship (tick one): Carer □ Relative □ Friend □
Continued on the next page …..
The patient must sign below to show that they have consented to allow proxy access:
Signed: ……………………………. Date: ……………………………….
Services required
By default we assume that repeat medication ordering and appointment booking will be required; select other services from the list below:
Ordering medication √ / Summary medical record view □ / View test results * □Book GP Appointments √ / Detail medical record view* □ / Complete questionnaires □
*Denotes a service not yet available
Identity verification – document supplied:
Passport □ / Utility bill □ / Birth certificate □Photo driving licence □ / Bank statement□ / Marriage certificate □
Signature of staff member confirming identity check: …………………………………….
Post the form to us at the above address with a photocopy of your identity document or bring both in to be checked at reception.
We will register your details as quickly as we can. You will receive your log in information by post. You cannot use the system until you receive your user name and password.
The system is a hosted on a secure website operated by our clinical system provider. We cannot be held responsible for any problems with this service. There is a link to the secure system on our website home page. You can download an app to access our online services on your mobile device – search for Systmonline in your app store.
Choose well for you and your family
We want to help you to choose well for you and your family. Research tells us that 40% of people that go to Accident and Emergency (A&E) don’t need to be there, and that parents of children aged 0-4 years old are among the most frequent users of A&E.
There are some circumstances when you will definitely need A&E but did you know about the alternative local NHS services where you may be seen more quickly and appropriately?
For example, did you know:
Pharmacists can advise you on a range of childhood illnesses and medicines?
There are minor injury units in Northampton and Corby, and an 8am to 8pm walk in centre in Corby?
You can get professional and confidential health advice over the telephone from NHS Direct 24 hours a day, seven days a week?
This briefing is to help you choose the right services for you and your family.
You can also find more information on our Choose Well campaign at www.northamptonshire.nhs.uk/choosewell
Self careGrazed knee.
Sore throat.
Runny nose / There are a range of minor illnesses and injuries that in many circumstances you can deal with at home if you have the right things in your medicine cabinet. A well stocked medicine cabinet should include the following items:
v Children’s paracetamol – This can be given to children over two months for pain and fever. Make sure you’ve got the right strength for your child. Overdosing is dangerous. Check with your pharmacist when you buy it, and read the label carefully.
v plasters, triangular bandage and two sterile eye dressings
v small, medium and large sterile gauze dressings
safety pins / v Children’s ibuprofen – This can be given to children over three months for pain and fever if they weigh more than 5kg (11lbs). Check the correct dose for your child’s age, and avoid ibuprofen if your child has asthma, unless advised by your GP
v Tweezers, scissors and stick tape
v alcohol-free cleansing wipes
v thermometer, preferably digital
v disposable sterile gloves
Important: Keep your medicines safe from little ones at all times by locking your medicine cabinet. Always read the label and check that you are giving the correct dosage. Do not give aspirin to children under 16 unless prescribed by a doctor, and if you are breastfeeding, ask a GP, midwife or health visitor for advice before taking aspirin.