Vine Medical Group Patient Registration Form Your Information

Transcription

1 Your Information Welcome to Vine Medical Group. In order for us to offer you the high standards of clinical care we give to our patients, we ask that you complete this registration form. Before we are able to register you as a patient, you will need to bring along suitable identification, including photographic ID (such as a passport, UK photocard driving licence or nationally recognised photo ID), and two proof of address documents (such as a utility bill or recent bank statement). Please ask a receptionist for more information on what qualifies as suitable identification. 1. Personal Details Title Mr / Miss / Mrs / Ms / Master / Dr Family Name (Surname) Given Name (First name) Middle Name(s) Date of Birth Gender Marital Status Male Married Female Divorced Single Ethnicity British or Mixed British Indian or British Indian White British Pakistani or British Pakistani Irish Bangladeshi or British Bangladeshi White Irish Other Asian Background Other White Caribbean White and Black Caribbean African White and Black African Other Black Background White and Asian Chinese Other Mixed Background Ethnic category not stated We would be very interested to know... Please tick this box if you have any relatives or friends who are employed by Vine Medical Group. Have you visited out website before? STAFF USE If ticked above, advise patient of staff records access policy. How did you hear about us? 2. Home Address House Name / Flat Number Number & Street Locality Town/City County Postcode 3. Contact Details Home Tel Work Tel Mobile Tel Address 4. Communicating with you As a new patient, if you provide your address we may send you short questionnaires a couple of times a year, to get your feedback on how the practice is run and on the services we offer. This is known as the Virtual Patient Participation Group (VPPG). We will not share your details with any 3rd party, and you feedback is valuable in ensuring we offer you the best possible service. We may also send you s regarding new services or information regarding the practice, such as flu clinics. If however you would not like to participate, please tick this box. If you provide your mobile telephone number, we can send you SMS text reminders for your upcoming appointments, as well as useful information such as flu clinics. If you would not like to receive these, please tick this box. Updated March 2016

2 Your Information - cont 5. Next Of Kin Relationship to you Title Family Name Given Name Date of Birth House Name / Flat Number House Number & Street Locailty Town / City County Postcode Home Telephone Work Telephone Mobile Telephone Emergency Contact Can Discuss Record Mr / Miss / Mrs / Ms / Master / Dr 6. Do you have a carer? Please complete this section if you are dependent on someone for some or all of the time. Name of Person Contact Phone Relationship To You 7. Are you a carer? Please complete this section if you look after someone who is dependent on you for some or all of the time. Name of Person Contact Phone Relationship To You Is this person a patient at Vine Medical Group? 8. Declaration By signing below, you are declaring that the information contained within this patient registration form is accurate to the best of your knowledge. Any suspected fraudulent information will be reported the the relevant authorities. Signature Today s Date: Time: ID 1: ID 2: FOR OFFICE USE ONLY - NOT TO BE COMPLETED BY PATIENT Staff Processing (Print Name): Checked By (Print Name): Date / Time:

3 Sharing of Medical Record Information Please read the following sections carefully regarding the sharing of information. If you would like to opt out of any of the following, please tick, sign and date the relevant sections. 10. Hampshire Health Record (HHR) The Hampshire Health Record is a local scheme that allows Out of Hours, Ambulance and Emergency services as well as GPs and Hospital Consultants access to medical record data. Patient consent will be required each time by anyone accessing their medical records (unless they are unconscious). If you would like to opt out of the HHR scheme, please tick below, and sign and date. I would like to OPT OUT of the HHR Signed Date HHR information line: Summary Care Record (SCR) The Summary Care Record is a national scheme and is used to support your emergency care. The information will be very limited, and may include medication, allergies and adverse drug reactions. Patient consent will be required each time by anyone accessing their medical records (unless they are unconscious). If you would like to opt out of the SCR scheme, please tick below, and sign and date. I would like to OPT OUT of the SCR Signed Date SCR information line: Care.data Information from your medical records can be used by the NHS to improve the services. Information, (which does not reveal your identity), is sent to a secure system where it can be linked with other health information. It helps compare the care you receive in one area against another, as well as providing data for research work and care planning. If you would like to opt out of the Care.data scheme, please tick below, and sign and date. I would like to OPT OUT of Care.data Signed Date More information available at

4 Health Check Information 1) Do you smoke? Never Ex Smoker 2) How much on a daily basis do you / did you smoke? If you ticked 'Never', please skip to question 3. 3) How often do you have a drink containing alcohol? Never Monthly or less times per month 2-3 times per week 4+ times per week For questions 4 and 5, 1 unit is equal to 1/2 pint beer or 1 small glass of wine or 1 pub spirit measure. 4) How many units of alcohol do you have per week on average? 5) How many units of alcohol do you drink on a typical day when you are drinking? ) How often have you had 6 or more units if female, or 8 or more units if male, on a single occasion in the last year? Never Less than monthly Monthly Weekly Daily or almost daily ) Do you have any of the following conditions? Heart Disease Stroke High Blood Pressure Diabetes Asthma COPD/Emphysema Epilepsy Thyroid Disease 8) Do any of your family members have a history of or problems with: Hypertension If yes, please specify family member Cancer FOR OFFICE USE ONLY Smoking cessation info given? ACTIONED? (Please tick) Heart Disease Stroke High BP Diabetes Asthma COPD/Emphysema Epilepsy Thyroid Disease Cancer Weight AUDIT-C Q3 Score Q5 Score Q6 Score AUDIT-C Score (Q3+Q5+Q6) If 5+ book appt with HCA kg CVA / Stroke Height cm Diabetes Asthma Systolic Blood Pressure Breast Cancer Cancer of Gastrointestinal Tract Ischaemic Heart Disease (IHD) Diastolic Blood Pressure If yes to IHD, was/is the family member... Under 60 yrs? Over 60 yrs? Urine sample? 9) Do you have any allergies? If you ticked '' to the above, please complete the following: Details of allergy, (i.e. reaction):

5 Online Services If you wish, you can now use the internet to book appointments with a GP, request repeat prescriptions for any medications you take regularly and look at parts of your medical record online. You can still use the telephone or call in to the surgery for any of these services as well. Being able to see your record online might help you manage your medical conditions. It also means you can even access it from anywhere in the world should you require medical treatment on holiday. If you would like to use this service, please indicate below the services you would like to use and sign the declaration. Unfortunately we cannot currently offer online access to any patients under the age of 16, in person or by proxy. Please note that Vine Medical Group reserve the right to decline or remove online access if it is not used 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. We will explain the reason for withdrawing access to you and will re-instate access if and when appropriate. It is your responsibility to keep your login details safe and secure. If you know or suspect that your record has been accessed by someone else without your permission, you should change your password as soon as possible. If you are not able to do that, please let us know as soon as possible so that we can remove online access until you are able to come in and request new login details. If you print out any information from your record, it is your responsibility to keep it secure. The information you can see online may be misleading if you rely on it alone. Our clinicians will endeavour to ensure any comments are written in easy-to-understand terminology, however due to the nature of medical conditions this may not always be possible. If you have any queries relating to your medical record online, we would advise you speak to a member of our duty team by calling for a telephone consultation. Please select your online services: Would you like to be able to book appointments with a GP online? Would you like to be able to request repeat prescriptions online? Would you like to be able to view parts of your medical record online? Please specify the contact details for your online services account: address: Mobile number: Please note, to use our online services you must complete the online services registration at home on your computer. Full instructions will be supplied to you by the receptionist processing your application. Declaration By signing below, you are declaring that you accept the conditions of online access as set out above, and that you fully acknowledge the benefits and risks of having access to your medical record enabled for online access. Signature Today s Date: