Medical Group 

Patient’s Name:				                  Date of birth:

Registration Checklist 
To prevent delays in processing this application form, all documents must be checked and verified that they have been completed correctly.
Staff Initials (who checked the form):__________

	Tick 
	N/A	
Patients full name (check spelling)
 			
Patients DOB and place of birth
			
Current home address & post code
			
Previous home address & post code
			
Telephone number
			
Previous GP address
			
If the patient has no previous GP address, ask the following:

Is this the first time you’ve registered at the GP Practice?

Are you new to the UK?

If new to UK – remember ID is needed 

What date did you take residency in the UK?
			
If returning from armed forces check all details are gathered 
			
Please request the following information:

Marital status:

Email:

First Language:
			
Signed and dated?
			
Has patient nominated a Pharmacy or the Dispensary?
			
Are all sections of the Health questionnaire completed?
			
Is the consent form completed and signed correctly? (check only one consent box is ticked)			
Check with patient re opiate drugs – if applicable please ask patient to sign consent form (need list of prescription drugs to be handed with registration where possible ) 			
Check online services form completed correctly (if patient would like access)

ASA Medical Group

New Patient Health Questionnaire for Adults

Please complete any areas with *

Your Contact Details* 

Title                                          
Mr  Mrs  Miss  Ms  Other 		Surname  

Date of Birth    				First Names  

Occupation  					Previous Surnames  
      
Home Address

Postcode:

Home Tel  						
Mobile
Work Tel  						
Email  
Please provide an email address where possible

What is your first language?  

Ethnic Group*
 
    	White 	British  		Irish 		Other   Please State:
      
Black 	Caribbean 		African 		Other   Please State:
      
	Asian 	Indian     	Pakistani 	 	Chinese   						Other  Please State:
      
	Mixed 	White + Black 	Caribbean White + Black African 
      		White + Asian 	Other  Please State:

     Do you need an interpreter?    Yes/No

Previous GP* 
      
Name and Address of Previous GP 

Medical Information* 

Please list any serious illnesses / operations / accidents / disabilities and for women any pregnancy related problems) and the year they took place:

 

       
Have you ever suffered from? (tick as appropriate)* 

Epilepsy 			Yes / No 	Blindness/Glaucoma 	Yes / No 
High Blood Pressure 	Yes / No 	Diabetes 			Yes / No 
Heart Attack/Stroke 	Yes / No 	Depression 		Yes / No 
Cancer 			Yes / No 	Asthma 			Yes / No 
Eczema/Hay Fever 	Yes / No 	COPD 				Yes / No 

Please list any medicines being taken and the amount:* 

       
Are you registered disabled?* (If yes, please give details) Yes / No

Are you allergic to any medicines and if so, which?* 
Yes / No

       
Have you ever refused treatment/screening of any kind and if so, what?* 
Yes / No 

Have you ever suffered from?* (tick as appropriate) 

Anxiety 		Yes / No 		Depression Yes / No 
OCD 			Yes / No  		Bipolar Disorder Yes / No 

Do you have any other mental health issues?* (If yes please give details) 

       
Are you receiving or have you received any treatment or therapy?* (If yes please give details) 

Carers* 
      
Do you have a carer? (If yes please give details) Yes / No

Are you a carer? (If yes please give details) Yes / No 

    

Women* 
Have you ever had a cervical smear?  Yes / No 
(Please state the last date)  

Smoking* 

Do you smoke?  Yes / No 
      
If 'No', have you ever smoked?  Yes / No 
      
If you do currently smoke, how many cigarettes or ounces of tobacco do you smoke per week? 
       
Would you like advice on giving up smoking?  Yes / No 

Exercise*

How much exercise do you take?
Please tick

None ………………  Light ………………    Moderate ……………………  Vigorous …………………

     
Family History* 

Please state any serious illness of immediate family. Please state your relationship to the individual and their age and in the case of cancer, the type of cancer.

Condition                        Relationship      Age of onset(Approximate)

Asthma 			Yes / No   ………………………………………   ………………………………………………
Diabetes 			Yes / No   ………………………………………   ………………………………………………     
Epilepsy 			Yes / No   ………………………………………   ………………………………………………     	 
High Blood Pressure 	Yes / No   ………………………………………   ………………………………………………    	
Angina/Heart Attack 	Yes / No   ………………………………………   ………………………………………………     
Stroke                Yes / No   ………………………………………   ………………………………………………
Cancer 			Yes / No   ………………………………………   ……………………………………………… 
Type of cancer   …………………………………………………………………………………………………………………………………………     

     

      
Next of Kin* 

Relationship to you 

Name 

Address

Telephone number

       
For patients aged 65 and over or those with a chronic disease* (e.g. asthma or diabetes) 
      
Have you had a flu vaccination? Enter date or 'never':  

Have you had a pneumococcal vaccination? Enter date or 'never'  

Signature:

Date: 

ASA Medical Group
Armthorpe, Mere Lane, DN3 2DB
The Sandringham Centre, Intake, DN2 5JH
Auckley Surgery, 41 Ellers Lane, DN9 3HY
Tel: 01302 986110
Access to GP Online Services Form
Surname	
	
First name	
	
Date of birth	
	
Address

Postcode	
	
Email address	
	
Telephone number	
	Mobile number		

I wish to have access to the following online services (tick all that apply):
Booking appointments		
Requesting repeat prescriptions		
Accessing Test Results, Immunisations and Problems		

It will be your responsibility to keep your login details and password safe and secure.  If you know or suspect that your record has been accessed by someone that you have not agreed should see it, then you should change your password immediately.

If for any reason you cannot do this, we recommend that you contact the practice so that they can remove your online access until you are able to reset your password.

If you print out any information from your records, it will be your responsibility to keep this safe and secure.  If you are at all worried about keeping printed copies safe and secure, we recommend that you do not make copies at all. 

Before you apply for online access to your record, there are some other things to consider.
Although the chances of any of the following happening are very small, you will be asked if you have read and understood the following before you are given login details from our Staff Member.

Forgotten history 
There may be something you have forgotten about in your record that you might find upsetting. 	
Abnormal results or bad news  
If your GP has given you access to test results or letters, you may see something that you find upsetting to you. This may occur before you have spoken to your doctor or while the surgery is closed and you cannot contact them. 

	

I wish to access my medical record online and understand and agree with each statement (please tick)
I have read and understood the information on the reverse of this form		
I will be responsible for the security of the information that I see or download		
If I choose to share my information with anyone else, this is at my own risk		
I will contact the practice as soon as possible if I suspect that my account has been accessed by someone without my agreement		
If I see information in my record that is not about me, or is inaccurate I will log out immediately and contact the practice as soon as possible		

Signature	

	Date		

For practice use only
Identity verified through
(tick all that apply)	Vouching 
Vouching with information in record    
Photo ID 
Proof of residence 	Name of Verifier	Date	
Staff Name authorising
Access
		Date	

Important Information – Please read before returning this form

If you wish, you can now use the internet/mobile phone to book appointments with a GP, request repeat prescriptions for any medications you take regularly, look at your test results, Immunisations and medical records all online. Also, you can still call the surgery for any queries regarding the above services.  It’s your choice.

It will be your responsibility to keep your login details and password safe and secure.  If you know or suspect that your record has been accessed by someone that you have not agreed should see it, then you should change your password immediately.

If for any reason you cannot do this, we recommend that you contact the practice so that they can remove your online access until you are able to reset your password.

If you print out any information from your records, it will be your responsibility to keep this safe and secure.  If you are at all worried about keeping printed copies safe and secure, we recommend that you do not make copies at all. 

Before you apply for online access to your record, there are some other things to consider.
Although the chances of any of the following happening are very small, you will be asked if you have read and understood the following before you are given login details from our Staff Member.

Forgotten history 
There may be something you have forgotten about in your record that you might find upsetting. 	
Abnormal results or bad news  
If your GP has given you access to test results or letters, you may see something that you find upsetting to you. This may occur before you have spoken to your doctor or while the surgery is closed and you cannot contact them. 

	
Choosing to share your information with someone 
It’s up to you whether or not you share your information with others – perhaps family members or carers. It’s your choice, but also your responsibility to keep the information safe and secure.  	
Coercion 
If you think you may be pressured into revealing details from your patient record to someone else against your will, it is best that you do not register for access at this time.	
Misunderstanding Medical Information 
Your medical record is designed to be used by clinical professionals to ensure that you receive the best possible care.  Some of the information within your medical record may be highly technical, written by specialists and not easily understood. If you require further clarification, please contact the surgery for a clearer explanation. 	
Information about someone else 
If you spot something in the record that is not about you or notice any other errors, please log out of the system immediately and contact the practice as soon as possible.	
Further Information
For more information about keeping your healthcare records safe and secure please visit our website: https://www.asamedicalgroup.co.uk/

ASA Medical Group
Armthorpe, Mere Lane, DN3 2DB
The Sandringham Centre, Intake, DN2 5JH
Auckley Surgery, 41 Ellers Lane, DN9 3HY
Tel: 01302 986110

Name:					       	                     DOB:

CONSENT TO SHARING PATIENTS MEDICAL RECORDS

Would you consent to sharing your medical records with other external agencies dealing your healthcare i.e. Health Visitors, District Nursing Team, Chiropody, Sexual Health, Smoking Cessation and Mental Health Services etc.

                       Yes		                                No

Would you consent to the Practice viewing information you’ve agreed to share with other external agencies?

                       Yes			                     No

	

I can confirm that this information provided is correct and current. I agree to take part in a new patient check appointment and to provide all the information asked of me.

Signed……………………………………………………………………………………

Date……………………………………………………………………………………..

Information for new patients: about your Summary Care Record
Dear Patient,
If you are registered with a GP practice in England you will already have a Summary Care Record (SCR), unless you have previously chosen not to have one. It will contain key information about the medicines you are taking, allergies you suffer from and any adverse reactions to medicines you have had in the past.
Information about your healthcare may not be routinely shared across different healthcare organisations and systems. You may need to be treated by health and care professionals that do not know your medical history. Essential details about your healthcare can be difficult to remember, particularly when you are unwell or have complex care needs.
Having a Summary Care Record can help by providing healthcare staff treating you with vital information from your health record. This will help the staff involved in your care make better and safer decisions about how best to treat you.
You have a choice
You have the choice of what information you would like to share and with whom,
Authorised healthcare staff can only view your SCR with your permission. The information shared will solely be used for the benefit of your care.
Your options are outlined below; please indicate your choice on the form overleaf.
 Express consent for medication, allergies and adverse reactions only. You wish to share information about medication, allergies for adverse reactions only.
 Express consent for medication, allergies, adverse reactions and additional information. You wish to share information about medication, allergies for adverse reactions and further medical information that includes: Your illnesses and health problems, operations and vaccinations you have had in the past, how you would like to be treated (such as where you would prefer to receive care), what support you might need and who should be contacted for more information about you.
•	Express dissent for Summary Care Record (opt out). Select this option, if you DO NOT want any information shared with other healthcare professionals involved in your care.
If you chose not to complete this consent form, a core Summary Care Record (SCR) will be created for you, which will contain only medications, allergies and adverse reactions.
 Once you have completed the consent form, please return it to your GP practice.
You are free to change your decision at any time by informing your GP practice.

	

Summary Care Record Patient Consent Form
Having read the above information regarding your choices, please choose one of the options below and return the completed form to your GP Practice:
Yes — I would like a Summary Care Record
    Express consent for medication, allergies and adverse reactions only.
or
    Express consent for medication, allergies, adverse reactions and additional information.
No — I would not like a Summary Care Record
 Express dissent for Summary Care Record (opt out).
Name of Patient ___________________________________

Date of Birth _________  
Patient's Postcode _______
Surgery Name _______________________ Surgery Location (Town) _____________
NHS Number (if known) _______________
Signature ___________________	Date __________
If you are filling out this form on behalf of another person, please ensure that you fill out their details above; you sign the form above and provide your details below:
Name _________________________
Please circle one:	
Parent	
Legal Guardian	
Lasting power of attorney for health and welfare
If you require any more information, please visit http://systems.digita!.nhs.uk/scr/patients or phone NHS Digital on 0300 303 5678 or speak to your GP Practice.
For GP Practice use only 
To update the patient's consent status use the SCR consent preference dialogue box and select the relevant option or add the appropriate read code from the options below;
Summary Care Record Consent Preference	Read 2	CTV3	
The patient wants a core Summary Care Record (Express consent for medication, allergies and adverse reactions only)	9Ndm.	XaXbY	
The patient wants a Summary Care Record with core and additional information (Express consent for medication, allergies, adverse reactions and additional information)	9Ndn.	XaXbZ	
The patient does not want to have a Summary Care Record (Express dissent for Summary Care Record (opt out)	9Ndo.	XaXj6