Please print off all the relevant forms and bring to reception along with your GMS1

Please also visit the website sections on Summary Care Records and Care data

Audley Health Centre

Please help us by providing information about your ethnic group and first language.

Please fill in the form on the other side of this page

Why we are collecting information about your ethnic group and first language

Everyone belongs to an ethnic group or has a first language, so all our patients are being asked to describe their ethnic group and first language. We are collecting this information to help the NHS and Social Services to:

  • Understand the needs of patients and service users from different groups and so provide better and more appropriate services for you
  • Identify risk factors – some groups are more at risk of specific diseases and care needs, so ethnic group data can help treat patients and support service users by alerting staff to high risk groups
  • Improve public health by making sure that our services are reaching all of our local communities and that we are delivering our services fairly to everyone who needs them
  • Comply with the law as the Race Relations (Amendment) Act 2000 gives public authorities a duty to promote race equality and good race relations, and ethnic monitoring is important in making sure that race discrimination is not taking place.
  • The 16 ethnic groups used are standard categories for collecting ethnic group information. Using these codes will help us to compare information about the groups using our services with information from the census which tells us about our local population.

The list of groups is designed to allow most people to identify themselves. This list is not intended to leave out any groups of people, but to keep the collection of ethnic information simple. It is important to us that you are able to describe your own ethnic group and first language

If you need to complete any of the boxes labelled ‘any other group’, then please give some details so that we can better understand your needs

You do not have to complete the question but providing this information is very important. It will help us with diagnosis and assessment of your needs, and it will also help us to plan and improve our service. The information you provide will be treated as part of your confidential NHS record. The NHS and Social Services have strict standards regarding data protection and your information will be carefully safeguarded.

If you have any concerns or questions regarding this request or you want to make any comments or complaints about the collection of this information, or in the way in which you have been treated by staff requesting this information, please contact the Practice Manager.

Audley Health Centre

The Department of Health has asked us to record the ethnic origin and first language of all patients

This information will be added to your medical record

If you do not wish to provide this, please tick the ‘information refused’ box at the end of the list

Name: ……………………………………………Date of birth……………………..

Ethnic origin (please tick the description which you feel is most appropriate) / First Language (please tick the description which you feel is most appropriate)
White – British / English
White – Irish / French
Other White background / Spanish
Mixed – White and Black Caribbean / Italian
Mixed – White and Black African / German
Mixed – White and Asian / Hindi
Other mixed background / Punjabi
Asian or Asian British – Indian / Urdu
Asian or Asian British – Pakistani / Bengali
Asian or Asian British – Bangladeshi / Cantonese
Other Asian background / Mandarin
Black or Black British – Caribbean / Arabic
Black or Black British – African / Other –please name
Other Black background / Information refused
Chinese
Other Ethnic background
Information refused

Please bring this completed form with you to your first appointment with the doctor or nurse. It is important that you are seen within the first six weeks of registering

Audley Health Centre – New Patient Registration – Adult

We would be grateful if you could provide the following information in order to register as a new patient here.

Name:…………………………………………………………………………………..

Address………………………………………………………………………

………………………………………………………………………………….

Post code………………………………Telephone Number……………………………

Date of Birth…………………………...Sex M/F

Marital Status M / S / W / D NHS Number……………………..

Please indicate if you suffer, or have suffered from any of the following: please circle

DiabetesStroke/TIAAngina/Heart AttackEpilepsy

High Blood PressureAsthma/COPDThyroid Disease

Other Past illnesses / Operations - please list below with dates:

Investigations & Immunisations:

Flu vaccination…………….(date done) Pneumonia……………...(date done)

Smear………………………(date done)Tetanus:………………….(date done)

Current Medication (inc. over the counter from the chemist)

Allergies (drugs and other)

Smoking Status: Yes……..amount No stopped Never

Please circle

Alcohol………………………Units per week………………………….

Exercise: Daily/ Weekly / Monthly / Rarely What type?…………………….

To be completed by the doctor / nurse Date……………

Height:………………………………………Weight……………………………………..
BP…………………………………………...Urinalysis………………………………….
Family History………………………………………………………………………………
Contraception………………………………………………………………………………

Drs Page,Turner, Hall and Sutton

Audley Health Centre

New Patient Registration, child aged 5 - 16

We would be grateful if you could provide the following information in order to register as a new patient here.

Name:…………………………………………………………………………………...

Address…………………………………………………………………………………

………………………………………………………………………………….

Post code………………………………Telephone Number……………………………

Date of Birth…………………………...Sex M/F

Name of main carer:……………………NHS Number………………………………..

School:………………………………………………………………………………….

Previous illnesses / operations / hospital follow-up:

Investigations & Immunisations:

Up to date: Y/N

Any reactions/problems:

Current Medication (inc. over the counter from the chemist)

Allergies (drugs and other)

TO BE COMPLETED BY THE DOCTOR / NURSE DATE:………………..

Height: …………………………. Weight:………………………………. Urinalysis…………………………….

General Health……………………………………………………………………….

NAME...... Date of Birth......

Audley Health Centre Applications to EMIS Patient Access

Please complete this form for online access the Emis patient access on your mobile or PC, you will need bring in this completed form and two types of ID – one must be a photo ID i.e. passport , photo driving licence, Bus pass,and a letter with proof of address. We will forward your password to your email address usually within 10 days –.If you have no Photo iD you can be vouched for by a member of staff that knows you. Over 16’s need own email address and ID,s. Under 16’s can go on parents.

Are you a new patient□ Yes □ No if yes access may take up to 2 months

Surname / Date of birth
First name
Address
Postcode
Email address/ over 16’s own email
Telephone number / Mobile number

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

  1. Booking appointments
/ 
  1. Requesting repeat prescriptions
/ 
  1. View Partial Health records(as per NHS guidelines)
/ 

I wish to access my medical record online and understand and agree with each statement (tick)

  1. I have read and understood the information leaflet provided by the practice
/ 
  1. I will be responsible for the security of the information that I see or download
/ 
  1. If I choose to share my information with anyone else, this is at my own risk
/ 
  1. I will contact the practice as soon as possible if I suspect that my account has been accessed by someone without my agreement
/ 
  1. If I see information in my record that is not about me or is inaccurate, I will contact the practice as soon as possible
/ 
Patient, guardian or carer Signature: / Date

1 and 2 above access to Appointments, medications only

3 above isPartial viewing of health records, immunisations, test results, allergies and summary of health problems. (Core services as per NHS Guidelines.)

For practice use only

Identity verified by (receptionist) upon collection, write in description.
Photo ID 
and proof of residence  / Initials Date
Authorised by
…………..signature / Date / Method Vouching 
Vouching with information in record 
Date online account created by who
Level of record access enabled
medications, appointments 
Detailed, all contractual with NHS. 
Limited parts 
Declined access / Notes / explanation
Core plus test results and imms
reason

Give photocopy to patient when they apply /original signed copy to admin /Scan to notes when completev7 feb17