Care home resident registration form

Patient's details

Title(Required)

First name(Required)

Middle names

Surname(Required)

Date of birth(Required)

Do you know the NHS number of the person you are registering?(Required)

You can find your NHS number by visiting the NHS website. For children, you can also find their NHS number in their Red Book.

Yes

NHS Number(Required)

Previous surnames(Required)

Please enter N/A if not applicable

Sex(Required)

Female

Male

Town and country of birth(Required)

Home address in the UK(Required)

Postcode(Required)

Telephone number(Required)

Email(Required)

Enter Email Confirm Email

Please help us trace your previous medical records by providing the following information

ALL previous addresses in UK(Required)

Please enter N/A if not applicable

Name of previous GP practice while at that address(Required)

Please enter N/A if not applicable

Address of previous GP practice while at that address(Required)

Please enter N/A if not applicable

If you are from abroad

If you are new to the country please supply a copy of your passport and visa to: [email protected]

Your first UK address where registered with a GP(Required)

Please enter N/A if not applicable

If previously resident in UK, date of leaving(Required)

Please enter N/A if not applicable

Date you first came to live in the United Kingdom(Required)

Please enter N/A if not applicable

NHS Organ Donor registration

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 tick the boxes that apply.

Please tell your family you want to be an organ donor. If you do not want to be an organ donor, please visit www.organdonation.nhs.uk or call 0300 123 23 23 to register your decision.

NHS Blood Donor registration

I would like to join the NHS Blood Donor Register as someone who may be contacted and would be prepared to donate blood.

Yes I would like to join the NHS Blood Donor Register

Tick here if you have given blood in the last 3 years

My preferred address for donation is: (only if different from above, e.g. your place of work)

All blood types are needed, especially O negative and B negative. Visit www.blood.co.uk or call 0300 123 23 23.

Non-UK European Health Insurance Card (EHIC), Provisional Replacement Certificate (PRC) details and S1 forms

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 state. Do not complete this section if you have an EHIC card issued by the UK.

Do you have a non-UK EHIC or PRC?(Required)

If you select yes please complete the additional details from your EHIC card that will appear below.

Yes

Country code(Required)

Name(Required)

Given names(Required)

Date of birth(Required)

Personal Identification Number(Required)

Identification number of the institution(Required)

Identification number of the card(Required)

Expiry date(Required)

PRC validity period (a) From:(Required)

PRC validity period (b) To:(Required)

S1 form

Please tick this box 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 practice staff.

Yes I have an S1 form

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.

More about who you are registering

Occupation/Job (current/past)(Required)

Please enter N/A if not applicable

Are you retired?(Required)

Yes

Are you homeless?(Required)

Yes

If you are homeless, may we use the address you registered with for confidential post?(Required)

Yes

Were you ever registered with an Armed Forces GP

Please indicate if you have served in the UK Armed Forces and/or been registered with a Ministry of Defence GP in the UK or overseas(Required)

Address before enlisting(Required)

Please enter N/A if not applicable

Postcode(Required)

Please enter N/A if not applicable

Service or Personnel number(Required)

Please enter N/A if not applicable

Enlistment date

Discharge date (if applicable)

Footnote: These questions are optional and your answers will not affect your entitlement to register or receive services from the NHS but may improve access to some NHS priority and service charities services.

Next of kin

Next of Kin full name(Required)

Relationship to you(Required)

Please enter N/A if not applicable

Next of Kin contact number(Required)

Do they have any formal power of attorney for medical care? (if so, please attach the certificates below)(Required)

Note, we will only contact this person in case of emergencies, and we will never share confidential information without your consent

Yes

Interpreter

Do you require an interpreter?(Required)

We offer double appointments for patients who need a language interpreter or BSL. Please ask at reception when booking an appointment.

Yes

Main language spoken(Required)

Lifestyle questions

Are you a smoker?(Required)

If yes – we offer smoking cessation services at the practice. Please tick if you would like more information about this.

Yes

Never smoked

Ex-Smoker

How many per day?(Required)

Please send me smoking cessation services information(Required)

Yes

When did you quit?(Required)

How often do you physically exercise?(Required)

Daily

Weekly

Occasional

What is your height?(Required)

What is your weight?(Required)

Alcohol consumption

Approximately - 1 drink = 1/2 pint of beer or 1 glass of wine or 1 single spirits. 1 unit of alcohol = 10cc of alcohol. So, a small glass (125cc) of 12% wine is 12.5 * 0.12 = 1.5 units. Find out more about alcohol units on the NHS website

How often do you have a drink containing alcohol?(Required)

How many units of alcohol do you drink on a typical day when you are drinking?(Required)

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?(Required)

Part one score

A total of 5+ indicates increasing or higher risk drinking.

Alcohol consumption – Part Two

How often during the last year have you found that you were not able to stop drinking once you had started?(Required)

How often during the last year have you failed to do what was normally expected from you because of your drinking?(Required)

How often during the last year have you needed an alcoholic drink in the morning to get yourself going after a heavy drinking session?(Required)

How often during the last year have you had a feeling of guilt or remorse after drinking?(Required)

How often during the last year have you been unable to remember what happened the night before because you had been drinking?(Required)

Have you or somebody else been injured as a result of your drinking?(Required)

Has a relative or friend, doctor or other health worker been concerned about your drinking or suggested that you cut down?(Required)

Yes, but not in the last year

Yes, during the last year

Score - part 2

0 – 7 Lower risk, 8 – 15 Increasing risk, 16 – 19 Higher risk, 20+ Possible dependence.

Further health questions

Do you have any allergies? YES (please specify)(Required)

Yes (please specify below)

Allergy details(Required)

Are you currently receiving care elsewhere?

Yes

Please provide further information(Required)

Please list below your current repeat medication(Required)

Pharmacy choice(Required)

We are a paper-free surgery, as such our prescriptions are all sent electronically to a pharmacy of your choice. Please let us know which pharmacy you would like prescriptions to be sent to (this can be changed at a future date).

Do you currently have or had any of the following?(Required)

Family history

Are you adopted?(Required)

Yes

Does anyone in your family have or previously had any of the following(Required)

Females only

Please let us know the date of your last cervical screening (smear) test

(if you are over 25 years old)

Have you had any children?(Required)

Yes

Please give the dates of birth of your children(Required)

Have you had a hysterectomy?(Required)

Yes

Please give the date of the hysterectomy(Required)

Do you have a coil or implant?(Required)

Yes

Please give the date when fitted(Required)

Protected characteristics (Equality Act 2010)

All the information given on this form will be kept in the strictest confidence, as part of your medical records.

Please only complete those sections you feel confident in completing or you feel are appropriate for the age of the patient. Please note that this information is helpful to our clinicians to allow them to provide you with the best quality and individualised service that we can offer.

Gender identity

At birth were you described as

Male

Female

Prefer not to say

Unable to answer

Have you gone through any part of a process (including thoughts or actions) to change from the sex you were described as at birth to the gender you identify with, or do you intend to? (This could include changing your name, wearing different clothes taking hormones or having any gender reassignment surgery).

Yes

Continuing to think about these examples, which of the following options best applies to you? Please tick one option

I am thinking about going through this process

I am currently going through this process

I have already been through this process

I have been through this process, then changed back

None of the above

I prefer not to say

Which of the following describes how you think of yourself? (tick all that apply)

I think of myself in another way as described here

Sexual orientation

Ethnicity

What is your ethnic group?

Choose one option that best describes your ethnic group or background

I describe my ethnicity as

What is your religion/belief

Disability

You're disabled under the Equality Act 2010 if you have a physical or mental impairment that has a 'substantial' and 'long-term' negative effect on your ability to do normal daily activities.

Do you have a learning disability?(Required)

Yes

Do you need information communicated to you in a specific format?(Required)

Yes

Do you need support when attending the surgery?(Required)

Yes

If yes, please describe any special help you require: (e.g. unable to manage stairs, easy-read information, sight/hearing assistance)

Patient Participation Group

Our Patient Participation Group (PPG) is chaired by patients and provides the practice with feedback on how we improve our service delivery to meet the needs of our patients. We are an enthusiastic group and are always looking for new members to contribute.

Please tick here if you would like to be added to our PPG mailing list, to receive news and invitations to PPG meetings

Yes please

Online services, text messaging & emails

To register for online services please download the NHS app. You can book/cancel appointments, order prescriptions and see your read coded records and results online.

Do you consent to receiving SMS messages?(Required)

Yes

Do you consent to receiving email messages?(Required)

Yes

Care home residents

Are you a care home resident?

Yes

Do you have a current PCSP in place?(Required)

Yes

How is your mobility?(Required)

Fully mobile

Reduced mobility

Chair ridden

Bed ridden

How would you rate your frailty?(Required)

Physically active

Mild frailty

Moderate frailty

Severe frailty

How would you rate your sight?(Required)

Normal vision

Impaired vision

Registered partially sighted

Registered blind

How would you rate your memory?(Required)

Memory normal

Memory impaired

Under the Memory clinic already

Are you a falls risk?(Required)

Yes

Please tell us the frequency of falls(Required)

Does not fall

Falls infrequently

Recurrent falls

Please give the number of falls in the last year(Required)

Please let us know your preferred place of care at End of Life(Required)

Please let us know your preferred place of death(Required)

NHS patient information sharing - my choices

This section of the form covers the Summary Care Record and the Enhanced Data Sharing Model 'SystmOne'. If you would like to know more about these things, please see the following links. NHS Health Records - Enhanced Data Sharing Model

Please complete and/or tick the boxes below to detail your personal decisions regarding the 2 aspects of NHS patient data sharing. It is very important you sign this form to say that you understand and accept the risks to your personal health care if you do decide to opt out of SCR or EDSM. You will need to do this when you next visit the surgery.

1. SCR - NHS SUMMARY CARE RECORD(Required)

Is a summary of a patient's sensitivities/allergies/current medication, which is uploaded to the national Spine. It can be accessed by any legitimate Clinician and is beneficial when a patient is seen at a hospital /Out of Hours/temporary resident at a GP practice. It is advisable to stay registered for this service.

Express consent for medication, allergies and adverse reactions only

Express consent for medication, allergies, adverse reactions and additional information

Express dissent – Patient does not want a summary care record and fully understands the risks involved with this decision

EDSM – ENHANCED DATA SHARING MODEL "SystmOne" Sharing Out – Do you consent to the sharing of data recorded by your GP practice with other NHS organisations that may care for you?(Required)

YES share data with other NHS organisations

NO do NOT share any data recorded by my GP Practice; I fully accept the risks associated with this decision

Sharing In – Do you consent to your GP Practice viewing data that is recorded at other NHS organisations and care services that may care for you?(Required)

Consent Given

Consent Refused; I fully accept the risks associated with this decision.

Signature

You will be asked to sign this form when you visit the practice and provide ID and proof of address. If you were born outside of the UK, bring your Passport and Visa with you.

Please enter your full name below

Today's date

Name

This field is for validation purposes and should be left unchanged.

Contact us online

Patient's details

Please help us trace your previous medical records by providing the following information

If you are from abroad

NHS Organ Donor registration

NHS Blood Donor registration

Non-UK European Health Insurance Card (EHIC), Provisional Replacement Certificate (PRC) details and S1 forms

More about who you are registering

Were you ever registered with an Armed Forces GP

Next of kin

Interpreter

Lifestyle questions

Alcohol consumption

Alcohol consumption – Part Two

Further health questions

Family history

Females only

Protected characteristics (Equality Act 2010)

Ethnicity

Disability

Patient Participation Group

Online services, text messaging & emails

Care home residents

NHS patient information sharing - my choices

Signature

Helpful links