Dr J Wright & Partners
New Patient Registration Form (Part 1)
PLEASE COMPLETE ASEPARATE FORM FOR EACH FAMILY MEMBER TO BE REGISTERED.
Please complete ALL sections in BLOCK CAPITALS and tick the boxes as appropriate.
If you are newly arrived in this country, please bring your passport to confirm your date of birth and entitlement to NHS treatment.
Full Name: / Telephone Number:Mr / Mrs / Miss / Ms / Other…….. / Work Number
Address and Postcode / Mobile Number:
E-mail Address:
Next of Kin:
Relationship to You:
Next of Kin Contact Number:
Date of Birth: / Previous / Mother’s surname if different: / Town & Country of Birth
Marital Status: / Gender: / Male: / Female: / Occupation
Names & Ages of Children / Name of person with parental responsibility for this child.
(please provide evidence)
For School Aged Children Only
Name of School currently attending / Registered Dentist:
Housing
(Select one) / House / Maisonette / Flat / Mobile Home / NHS Number (If Known)
Other residents of your home: / Previous Postcode:
Previous Doctor Telephone No.
Previous Address:
Have you ever been registered at this Practice before? / Previous Doctor Name & Address:
/ Country of Birth
Is this your first registration with a Doctor in the UK? Yes No
If not please provide details of previous Doctor’s name and Practice Address below:
If returning from Armed Forces: / Your Service or Personnel Number / Your Enlistment Date
Are you a Military Veteran / Yes / No / Date of Discharge
Your
height: / Feet / inches / cm / Your
weight: / Stones / lbs. / kg
Your
Religion: / C of E / Catholic / Other Christian (state) / Buddhist / Hindu / Muslim
Sikh / Jewish / Jehovah’s Witness / No religion / Other religion (state)
Your Ethnic Origin:
(select one) / White (UK)
9i0 / White (Irish)
9i1% / White (Other)
9i2%
Caribbean
9i3 / African
9i4 / Asian 9i5 / Other Mixed
Background 9i6%
Indian /
Brit Indian 9i7 / Pakistani /
Brit Pakistani 9i8 / Bangladeshi / Brit Bangladeshi 9i9 / Other Asian
Background 9iA%
Other Black
Background / Chinese
9iE / Other
9iF% / Ethnic Category
not stated 9iG
Your main or 1st language Spoken / Understood:
(select one) / English / Hindi / Gujurati / Urdu / Bengali /Sytheti / Punjabi
Polish / Ukrainian / French / German / Spanish / Other:
(Please
Specify)
HOUSEBOUND PATIENTS
Please tick appropriate box to indicate if you consider you are housebound / YES / NO
If you are a Carer, please state the name / address / phone number of the person you care for: / Person Cared For Contact Details:
If you have a Carer, please state their name address/phone number and sign here if you wish us to disclose information about your health to your Carer. / Carer Contact Details:
Signed: Date
Do you have a “Living Will”
(a statement explaining what medical treatment you would not want in the future)? / Yes / No / If “Yes”,
can you please bring a written copy of it
to your New Patient Consultation
Have you nominated someone to speak on your behalf (e.g. a person who has Power of Attorney)? / Yes / No / If “Yes”, please state their name/address/phone number:
Summary Care Records.
The NHS are changing the way your health information is stored and managed.
The NHS Summary Care record is an electronic record of important information about your health.
It will be available to health care staff providing your NHS Care. An information pack has been provided.
Are you happy to have a Summary Care Record? / Yes / No / More Time Required to decide:
Patient Participation Group
The Practice is committed to improving the services we provide to our patients.
To do this, it is vital that we hear from people about their experiences, views, and ideas for making services better.
By expressing your interest, you will be helping us to plan ways of involving patients that suit you.
It will also mean we can keep you informed of opportunities to give your views and up to date with developments within the Practice.
If you are interested in getting involved, please tick the box below and we will arrange for the Practice Patient Participation Group Application Form to be given to you at your initial consultation.
Yes, I am interested in becoming involved in the Practice Patient Participation Group (Please tick the “Yes” Box) / Yes
Text Alert Messages
If you are interested in receiving text alert messages to your mobile phone to remind you of appointments please indicate here Yes No
Register to use on line Appointment booking and Prescription Ordering
If you would like to register to use our on line appointment booking and prescription ordering services please indicate here Yes No
If Yes, please complete the attached form of authority.
Contact via E-mail
We may from time to time like to contact you via email to provide you with updates to our services etc.
If you would NOT like us to contact you in this way please indicate here.
Nominated Person for prescription collection
Please provide details below of a nominated person that you give permission to collect prescriptions from the surgery on your behalf.
Name ………………………………………………………………………… Telephone Number ……………………………………………………………
Relationship …………………………………………………………….. Address ……………………………………………………………………………..
…………………………………………………………………………………………………………………………………………………………………………………
Nominated Person with whom MHC can discuss issues regarding your health and provide test result information
Please provide details below of a nominated person with whom you give permission for MHC staff to discuss aspects regarding your health and provide test result information. Please tick if just for test results □
Name ………………………………………………………………………… Telephone Number ……………………………………………………………
Relationship …………………………………………………………….. Address ……………………………………………………………………………..
…………………………………………………………………………………………………………………………………………………………………………………
Updated July 2015
On-Line Appointment Booking and Prescription Ordering Service Guidance for EMIS Access.
Dear Patient
Before you begin to use EMIS Access we would appreciate it if you could read the following guidance regarding the booking of appointments over the internet. Please keep this page of the document for your own reference.
Reasons for Appointment
We would ask that you enter a reason for your appointment in the box provided when booking an appointment this gives us the opportunity to ensure that it is appropriate for you to see the doctor rather than a nurse. Please be assured that all details entered are secure and cannot be intercepted. Our practice has a strict confidentiality policy.
Missed Appointments
We would ask that if you will be unable to attend an appointment that you have booked online that you either contact us by telephone to cancel it or cancel it online. This will allow us to offer the appointment to another patient.
We realise that there are valid reasons for not attending however we will be monitoring such occurrences on a regular basis.
If you miss an appointment more than 3 times in one year we will remove your facility to use EMIS Access, however you will still be able to book appointments with our receptionists.
Nurses Appointments
Due to the nature of nurses appointments we are unable to offer them online. This is something that we hope we will be able to offer in the future.
Doctors Appointments
Please ensure that you book the appointments appropriately. If you are unsure as to whether it is appropriate for you to see a nurse or a doctor please contact us by telephone.
Doctors Appointments / Nurses AppointmentsSuspected illness / Smears
Illness / Childhood/baby immunisations
Follow ups to previous consultations / Pill Checks
Medication Reviews / Dressings, Ear syringes, removal of stitches.
Inappropriate use
We will be monitoring the use of this service and we are sure that you will find it most useful. If however we find that any users are abusing the service, we will revoke your access to the service and you will have to liaise with our reception team for services.
We would consider inappropriate use as: Sending inappropriate or abusive messages, booking appointments and not using them more than 3 times a year, booking appointments for other family members using your name, consistently booking inappropriate appointments with the doctor.
Messages
EMIS Access will give you a facility to send simple queries to the surgery. Replies to these queries will be sent to your EMIS Access homepage. You should not send urgent messages through this facility as we cannot guarantee that they will be read daily. Please do not send repeat requests through this service.
Practice Checklist for Registration for EMIS Access
Patient’s Date of Birth Checked and updated, if necessary.
Patient understands Registration Processand next step to registration.
Patient understands Practice EMIS Access Guidance.
Dear Doctors
I ………………………………………………………………………have understood and will adhere to the Practice Guidance for the use of EMIS Access. I understand that failure on my part to adhere to the guidance may result in my EMIS Access registration being terminated. I understand that this will in no way affect my registration with the practice.
Signed ______
Date of Birth ______
Dated ______