1x Proof of IDPrevious address info Previous GP Place of birth(Not UK born) Date of entryE Mail address Alcohol Questionaire Zero tolerance FormSignature

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DATE REGISTATION FORM RECEIVED:

FOR OFFICE USE:

RECEIVED BY:

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NEW PATIENT HEALTH QUESTIONAIRE EMIS No.Full NameDate of Birth

EmailLatent TB Screening:

Country of Birth:Have you been tested or treated for TB in the UK? YES NO

Are you aged between 16-35? If yes, have you lived in one of the countries below for a period of 6 months or more - in the last 5 years: (Please tick as appropriate):

Afghanistan Greenland Macedonia Nigeria Somalia

Bangladesh Guyana Micronesia North Korea East Timor

Bhutan Haiti Moldova Pakistan Uganda

Cambodia India Mongolia Papua New Guinea Vietnam

Georgia Indonesia Myanmar/Burma Philippines Any other African country (please specify)

………………………Ghana Laos Nepal Sierra Leone

Health Information

Height (cm) Weight (kg)Smoking Never Smoked Current smoker: Ex- smoker

Alcohol Questionnaire:

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Personal HistoryDo you suffer from any of these conditions?

Asthma YES NO Diabetes YES NO Heart Disease YES NO Hypertension YES NO Hypothyroidism YES NO Epilepsy YES NO COPD YES NO Stroke/TIA YES NO Heart Failure YES NO Chronic Kidney Disease YES NO

Cancer – please specify _________________________________________

Family History

Does/has anyone in your family suffer/suffered from any of the following

Heart Disease YES NO If yes – who __________________CVA/Stroke YES NO If yes – who __________________Diabetes YES NO If yes – who __________________Asthma YES NO If yes – who __________________Cancer YES NO If yes – who __________________

Next of Kin Name Relationship Telephone

Ethnic Category – 2001 CensusPlease tick as appropriate

White British British/mixed British Irish Other White White & Black Caribbean White & Black African White & Asian Other Mixed Indian Pakistani

Pakistani Bangladeshi Other Asian Caribbean African Other Black Chinese Not stated Other Please specify

Do you need an interpreter? YES NO

What is your main spoken language

Other infoAre you registered disabled? YES NO If yes please specify:

Carers Do you have a carer?

YES NO If yes please give details

Are you a carer?

YES NO If yes please give details

EPS PrescriptionsWe encourage all patients to register for Electronic Prescribing that will save them time and avoid unnecessary trips to the GP as the prescriptions are sent electronically. If you need prescriptions in the future please indicate the pharmacy of your choice

PHARMACY NAME PHARMACY LOCATION

Patient Online registration formAccess to GP online services

Surname

First name

Date of birth

Full Address

Email address

I agree that my Patient Access login details are sent to the above email address – PLEASE CIRCLE YES NO

Telephone number Mobile number

I wish to have access to the following online services (tick all that apply):

Booking appointments

Requesting repeat prescriptions

View Investigations ( Test Results), Allergies and Immunisation Records

Change Demographics

I understand and agree with each statement ( please tick)I have read and understood the information leaflet provided by the practice 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 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

Name of person who authorised(if applicable)

Date

Important Information Please read before returning this form

If you wish to, you can now use the internet to book appointments with a GP, request repeat prescriptions for any medications you take regularly and look at your medical record online. You can also still use the telephone or call in to the surgery for any of these services as well. 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 you can’t do this for some reason, we recommend that you contact the practice so that they can remove online access until you are able to reset your password.

If you print out any information from your record, it is also your responsibility to keep this secure. If you are at all worried about keeping printed copies safe, 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 these things happening are very small, you will be asked that you have read and understood the following before you are given login details.

Forgotten historyThere may be something you have forgotten about in your record that you might find upsetting.Abnormal results or bad newsIf 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 someoneIt’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.CoercionIf 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.Misunderstood informationYour 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 elseIf 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.

NHS ZERO TOLERANCE POLICY

I fully understand that the NHS is operating a permanent Zero Tolerance Policy towards violent and abusive behaviour.

This includes harassment, alarming, distressing, threatening behaviour, verbal abusive or insulting behaviour and violent behaviour by any individual. This policy applies to all Health Service facilities including all areas of general practice/primary care.

I further understand that should I be a party to violent, threatening or abusive behaviour toward any member of staff of a primary care facility then I will expect that certain sanctions will be applied to me. This could include removal from the general practitioners medical list or being seen at an approved secure centre for violent patients.

I am aware that difficulties may occur in the provision of my medical care that cannot be the responsibility of any one Healthcare professional. I am also aware that violent, threatening or abusive behaviour cannot alter this situation, which is often beyond the control of the individual professional.

I agree that on becoming a patient on the medical list of a Doctor within the Valentine Health PMS I will not use any form of violent, threatening or abusive behaviour toward any member of the staff.

PRINT NAME: _________________________________

Signed: ___________________________________

Date: ___________________________________

EMIS NUMBER: