1Your Details2Non-UK European Health Insurance3Previous Details4Next of Kin5Medical History6Medications7Family History8Carers9Summary Care Record10Alcohol11Patient Declaration1/11Your DetailsPatient's Details Title—Please choose an option—MrMrsMissMsDrOther Gender —Please choose an option—ManWomanTransgenderNon-binaryPrefer not to sayI use another term to describe myself Given Name Family Name Previous Surnames (If any) Middle Name(s) Known as/Preferred Name Date of birth NHS Number Marital Status —Please choose an option—SingleMarriedDivorcedSeperatedWidowedOtherI do not wish to disclose Town and country of birth What is your Ethnicity—Please choose an option—White - BritishWhite - IrishWhite - any other White backgroundMixed - White and Black CaribbeanMixed - White and Black AfricanMixed - White and AsianMixed - any other mixed backgroundAsian - IndianAsian - PakistaniAsian - BangladeshiAsian - any other Asian BackgroundBlack - CaribbeanBlack - AfricanBlack - any other Black backgroundOther - ChineseOther - Any other ethnic groupNot stated What is your first language? Do you require a translator? YESNO Your current Address House Name/Flat Number Street/Road name Town/City Post Code Your Contact Details Home Phone Mobile Phone Work Phone Email Preferred communication method —Please choose an option—No preferenceHome telephone numberWork telephone numberMobile telephone numberEmail addressLetter to home address Are you happy for us to contact you via these methods for appointment reminders and clinical services? Text message: YESNO Email: YESNO Next Complete this section if you live in another EEA country, or have moved to the UK to study or retire, or if you live in the UK but work in another EEA member state. Please DO NOT complete this section if you have an EHIC issued by the UK or are a UK resident SKIP THIS STEP NON-UK EUROPEAN HEALTH INSURANCE CARD (EHIC), PROVISIONAL REPLACEMENT CERTIFICATE (PRC) DETAILS and S1 FORMS Do you have a non-UK EHIC or PRC? YESNO If YES, Please enter details from your EHCI or PRC below: Country code: Name: Given Names: Date of birth Personal Identification Number: Identification Number of the Institution: Identification Number of the Card: Expiry date: PRC Validity period - a) From: PRC Validity period - a) To: Please tick if you have an S1 (eg. you are retiring to the UK or you have been posted here by your employer for work or you live in the UK but work in another EEA member state). Please give your S1 form to the practice staff. YESNO How will your EHIC/PRC/S1 data be used? By using your EHIC or PRC for NHS treatment costs your EHIC or PRC data and GP appointment data will be shared with NHS secondary care (hospitals) and NHS Digital solely for the purposes of cost recovery. Your clinical data will not be shared in the cost recovery process. Your EHIC, PRC or S1 information will be shared with The Department for Work and Pensions for the purpose of recovering your NHS costs from your home country. Anybody in England can register with a GP practice and receive free medical care from that practice. However, if you are not ‘ordinarily resident’ in the UK you may have to pay for NHS treatment outside of the GP practice. Being ordinarily resident broadly means living lawfully in the UK on a properly settled basis for the time being. In most cases, nationals of countries outside the European Economic Area must also have the status of ‘indefinite leave to remain’ in the UK. Some services, such as diagnostic tests of suspected infectious diseases and any treatment of those diseases are free of charge to all people, while some groups who are not ordinarily resident here are exempt from all treatment charges. More information on ordinary residence, exemptions and paying for NHS services can be found in the Visitor and Migrant patient leaflet, available from your GP practice. You may be asked to provide proof of entitlement in order to receive free NHS treatment outside of the GP practice, otherwise you may be charged for your treatment. Even if you have to pay for a service, you will always be provided with any immediately necessary or urgent treatment, regardless of advance payment. The information you give on this form will be used to assist in identifying your chargeable status, and may be shared, including with NHS secondary care organisations (e.g. hospitals) and NHS Digital, for the purposes of validation, invoicing and cost recovery. You may be contacted on behalf of the NHS to confirm any details you have provided. Please tick one of the following boxes a) I understand that I may need to pay for NHS treatment outside of the GP practiceb) I understand I have a valid exemption from paying for NHS treatment outside of the GP practice. This includes for example, an EHIC, or payment of the Immigration Health Charge (“the Surcharge”), when accompanied by a valid visa. I can provide documents to support this when requestedc) I do not know my chargeable status BackNext Previous details Previous address House Name/Flat Number Street/Road name Town/City Post Code Name and address of previous GP **If you were not born in the UK** Country of Birth Town of Birth Date of entry to U.K **If you are returning from abroad** Date you left the UK Date you returned to the UK If you are returning from the Armed Forces Address before enlisting Service/Personnel number Enlistment date BackNext Next of Kin Next of kin title —Please choose an option—MrMrsMissMsDr Next of kin first name Next of kin last name What is this person's relationship to you? Next of Kin Telephone Number (must be a British contact number) Is your next of kin registered/or will be registering at Elborough Street Surgery? YESNO BackNext Medical History Your Gender (Please tick the term that best reflects how you identify) ManWomanNon-BinaryI prefer not to sayI use another term to describe myself - please state below Are you trans/is your gender different to the one you were given at birth? YesNoI prefer not to say Your Sexual Orientation (Please tick the background that best reflects your sexual orientation) Heterosexual/StraightGay/LesbianBisexualI prefer not to sayOther - please state below What is your current smoking status? —Please choose an option—I have never smokedI am an ex-smokerI currently smoke Diabetes YesNo Date of Diabetes Diagnosis High Blood Pressure YesNo Date of High Blood Pressure diagnosis Heart Attack YesNo Date of Heart Attack diagnosis Asthma YesNo Date of Asthma diagnosis Stroke YesNo Date of Stroke diagnosis Cancer YesNo Date of Cancer diagnosis Type of Cancer? (e.g. bowel cancer, breast cancer etc) Mental Illness YesNo Date of Mental Illness diagnosis Disability YesNo Type of Disability Other Are you a housebound patient? (This means someone who is unable to leave their home environment due to a physical or psychological illness) YesNo BackNext Medications Please provide details of any medications you are currently being prescribed (or leave blank if you you are not on any medication) Current/Regular Medication Name: Medication Reason: Eg: Asthma, Diabetes etc Current/Regular Medication Name: Medication Reason: Eg: Asthma, Diabetes etc Current/Regular Medication Name: Medication Reason: Eg: Asthma, Diabetes etc Add any additional current/regular medications here: In an effort to support the NHS Paper Switch-Off Programme (PSO) we will no longer be printing prescriptions. Please ensure that you select a pharmacy below to have any future prescriptions sent through to electronically.* —Please choose an option—Asda Store - 31 Roehampton Vale, London, SW15 3DTAshburton Pharmacy - 30 Chartfield Avenue, London, SW16 6HGAukland Rogers Pharmacy - 892 Garratt Lane, London, SW17 0NBAura Pharmacy - 78 Inner Park Road, London, SW19 6DABoots Southfield - 31-33 Replingham Road, London, SW18 5LTBoots Tooting - 59-61 Mitcham Rd, Tooting, London SW17 9PBBoots Southside - 95-98 Southside Shopping Centre, London, SW18 4TGCooks Pharmacy - 6 Replingham Road, London, SW18 5LSD Parry - 124 Arthur Road, London, SW19 8AAFazal Pharmacy Limited - 197-199 Merton Road, London, SW18 5EFHusbands Pharmacy - 124 Upper Richmond Road, London, SW15 2SPMansons Dispensing Chemist - 195 Wandsworth High Street, London, SW18 4JERevelstoke Pharmacy - 492A Merton Road, London, SW18 5AESuperdrug - 104/105, Centre Court Shopping Centre, Wimbledon, London SW19 8YET.J Chemist - Thomas James Chemist, 385 Durnsford Road, London, SW19 8EFWellbeing Pharmacy - 13 Replingham Road, London, SW18 5LTOther - please state below If your pharmacy is not list please give us the Name and Address below Allergies Please provide details of any allergies that you have (or leave blank if you have no allergies) Name of Allergy: What happens? What is the reaction? Name of Allergy: What happens? What is the reaction? Add any additional allergies here: BackNext Family History Please enter details here if there is any relevant medical history in your family (or leave blank if there is none) High Blood Pressure —Please choose an option—MotherFatherSisterBrotherAuntUncleMaternal GrandmotherMaternal GrandfatherPaternal GrandmotherPaternal GrandfatherGrandmotherGrandfather Diabetes —Please choose an option—MotherFatherSisterBrotherAuntUncleMaternal GrandmotherMaternal GrandfatherPaternal GrandmotherPaternal GrandfatherGrandmotherGrandfather Mental Illness —Please choose an option—MotherFatherSisterBrotherAuntUncleMaternal GrandmotherMaternal GrandfatherPaternal GrandmotherPaternal GrandfatherGrandmotherGrandfather Stroke —Please choose an option—MotherFatherSisterBrotherAuntUncleMaternal GrandmotherMaternal GrandfatherPaternal GrandmotherPaternal GrandfatherGrandmotherGrandfather Cancer —Please choose an option—MotherFatherSisterBrotherAuntUncleMaternal GrandmotherMaternal GrandfatherPaternal GrandmotherPaternal GrandfatherGrandmotherGrandfather Heart Attack —Please choose an option—MotherFatherSisterBrotherAuntUncleMaternal GrandmotherMaternal GrandfatherPaternal GrandmotherPaternal GrandfatherGrandmotherGrandfather Asthma —Please choose an option—MotherFatherSisterBrotherAuntUncleMaternal GrandmotherMaternal GrandfatherPaternal GrandmotherPaternal GrandfatherGrandmotherGrandfather BackNext Carers Please provide details if you are a Carer, are Cared for, or are on an disability register (continue to the next question if not) Are you A CARER FOR a friend or a relative? —Please choose an option—NoYes Are you CARED FOR by a friend or a relative? —Please choose an option—NoYes BackNext Summary Care Record The Summary Care Record (SCR) is an electronic record of important patient information, created from GP medical records. It can be seen and used by authorised staff in other areas of the health and care system involved in your direct care. Access to SCR information means that care in other settings is safer, reducing the risk of prescribing errors. It also helps avoid delays to urgent care. As standard, the SCR holds: Your name, address, date of birth and NHS number Your current medication Your allergies and details of any previous bad reactions to medicines You can also choose to share an enhanced record. This is particularly useful if you are elderly, or have complex or long term conditions. The enhanced SCR holds: Significant medical history (past and present) Reason for medications Anticipatory care information (such as information about the management of long term conditions) End of life care information Immunisations Summary Care Record Consent* I consent to share standard information via the Summary Care Record.I do not consent to share any information via the Summary Care Record.I consent to share enhanced information via the Summary Care Record BackNext Alcohol Consumption Using the scoring system above, please score yourself between 0-4 for the following questions. If you do not drink, please enter 0 in all the boxes. How often have you had 6 or more units if female, or 8 or more if male, on a single occasion in the last year? How often during the last year have you been unable to remember what happened the night before because you had been drinking? Has a relative or friend, doctor or other health worker been concerned about your drinking or suggested that you cut down? YesNo BackNext PATIENT DECLARATION Online Access If you are 16+ and speak English fluently, you have the option to register for Patient Access allowing you to book and cancel routine GP appointments online, view blood test results and view your consultations and immunisation history online. If you do not speak English and require an interpreter for appointments, you will be unable to make appointments online. Please contact us to book appointments. (Required) Please specify if you would like to join Patient Access: YESNO To register for patient access please complete the application form below. Once we’ve received your application form we will then email you your login details. I wish to have access to the following online services (please tick all that apply): 1. Booking appointments YesNo 2. Requesting repeat prescriptions YesNo 3. Accessing my medical record YesNo I wish to access my medical record online and understand and agree with each statement (All of these fields are required) 1. I will be responsible for the security of the information that I see or download YesNo 2. If I choose to share my information with anyone else, this is at my own risk YesNo 3. If I suspect that my account has been accessed by someone without my agreement, I will contact the practice immediately YesNo 4. If I see information in my record that is not about me or is inaccurate, I will contact the practice as soon as possible YesNo 5. If I think that I may come under pressure to give access to someone else unwillingly I will contact the practice as soon as possible. YesNo Patient Acceptance (Required) I declare that the information I give on this form is correct and complete. I understand that if it is not correct, appropriate action may be taken against me. Yes Identification Please upload a copy of your driving licence, passport or ID card so as we can verify your identity. (File types accepted .png, .jpg and .pdf. Maximum file size 5mb) Signature (Required) Who is signing Signature of PatientSignature on behalf of patient Please sign in the box below using your mouse or on the screen of your tablet. (Required) Print name of signatory: (Required) By clicking submit you confirm that you have read and agreed our terms of service and terms of service and privacy policy (Required) Agree Back
