New Patient Questionnaire

Please complete this confidential questionnaire (one for each member of the family to be registered with the Practice). This should ONLY be used IN CONJUNCTION with the NEW PATIENT REGISTRATION (GMS1) FORM. All new patients will be asked to provide photographic identification and proof of address when registering with the surgery.

Last Updated: 30/03/2021

Your Contact Details










Next of Kin


Previous GP


Information About You











Smoking





Alcohol





Carers





Will



Medical Information










Family History



Women




For patients aged 65 and over or those with a chronic disease (e.g. asthma or diabetes)



Accessible Information Standard

All organisations that provide NHS or Adult Social Care must follow the Accessible Information Standard by law. The standard aims to ensure disabled people have access to information they understand. We as a surgery, want to make information accessible to everybody. This includes making sure people get information in different formats if they needs it, such as large print, Braille, Easy Read (pictures), email or telephone. Therefore we would like to ask the following:





Health Records Consent

Patients must consent to the sharing of their data held by one health provider to other health providers. Access to patient data is under the patients' control and can be shared on a 'need to know' basis if required. Your information is NEVER shared to any person or service not involved with your care. The surgery will automatically share information IN so that they can see your information from other care services, but will not automatically share your GP record out without your consent to do so. Please complete your choices below. Please note that we can share confidential information without consent if it is required by law, or directed by a court, or if the benefits to a child or young person that will arise from sharing the information outweigh both the public and the individual's interest in keeping the information confidential.

Record Sharing IN

This controls whether you agree for the practice to view information you've agreed to share at other NHS Care Services. Please record your preference below.


Record Sharing OUT

This controls whether your full GP electronic patient record can be shared with other NHS Care Services where you are treated. This allows other NHS providers such as secondary care providers, emergency care providers and community care providers with relevant medical information to assist them in providing your care.


Summary Care Record

Orchard Surgery shares part of your medical records (current medication & allergies) in an emergency, when you're on holiday, when the surgery is closed, at out-patient clinics or when you visit a pharmacy. We can add additional information to your Summary Care Record (SCR) from your medical notes, including: 1) Health problems (eg. Diabetes/Dementia/Stroke etc.) 2) Carer Details 3) Treatment Preferences 4) Communication needs (interpreter/hearing difficulties etc) What does it mean if you DO NOT have an SCR? 1) NHS staff caring for you may not be aware of your current medications and allergies, in order to treat you safely in an emergency. 2) Your records will stay as they are with information shared by letter, email or phone. 3) If you have any questions or if you want to discuss then please contact the surgery. Having read this information, please choose ONE of the options below.


Online Access

To register for our online services (SystmOnline) you will need to complete this form and then visit the practice, bringing with you two forms of identification. One of these items should include your photograph. We will then issue you a username and password. Please allow 3 working days before coming to the surgery. This will allow you to access services such as appointment booking and cancellations, medication requesting and viewing a summary of your medical record.




Online Access To Medical Records Questionnaire

This questionnaire is about Online Medical Record Access and goes through the main issues you need to understand before you can access your records over the internet. This is NOT a test with a pass or fail – its purpose is to go through issues with you so that you feel happy to be able to decide whether you wish to access your records.











Contacting You

From time to time, you may be contacted via SMS and/or email by the practice for the purposes of health promotion/information, appointment reminders, test results and forwarding information that may require action. This is an additional service and that any of these functions may not take place on occasion. Text messages/emails are generated using a secure facility, however they are transmitted over a public network onto a telephone/email and as such may then become insecure. The practice will NOT transmit any information which would enable an individual patient to be identified. You agree to advise the practice if your mobile number/email address changes. The practice does not share mobile phone contact details with any external organisation not involved in your care.


Parents of Children New To This Country, Please Note: We need you to provide details of your child's vaccination history (with proof) at the time of registering with the surgery.

Proof of Identity and Address

Select at least one from of photo identification and one proof of address that you are able to bring to the surgery to complete registration.


Signature