Dr Deverell, Dr Graeme-BarberDr. Nicola O’Shaughnessyand all their staff welcome you as new patients to The Old Dispensary. It would be very helpful if you could fill in this form as sometimes your notes take time to arrive or are incomplete. We look forward to meeting you.

Name / Date
Address:
Telephone No:
email: / Marital Status
Date of Birth
Occupation
Never Smoked / Ex. Smoker
Date stopped: / Smoker
Number per day:
Exercise (type and amount) / Height / Weight
Allergies
LIST ANY SERIOUS MEDICAL PROBLEMS INCLUDING OPERATIONS
Date / Date
LIST ALL MEDICATIONS YOU ARE AT PRESENT TAKING
Would you wish to have a flu vaccination if it were offered? / Yes/No
Do your relatives have (or have they had) any of the following? / Yes/No / Who (e.g. parents, grandparents, brother/sisters etc)? / Age
at onset / now / Or when deceased
Heart disease aged under 60
Stroke
High blood pressure
Diabetes
Breast cancer
Ovary cancer
Bowel cancer
Prostate cancer
DOYOU HAVE A CARER? YES/NO If YES please give details
Name:
Contact details:
Relationship:
N.B. IF YOU HAVE A CARER YOU HAVE THE RIGHT TO HAVE THEM WITH YOU AT YOUR APPOINTMENT SHOULD YOU WISH

NOW PLEASE TURN OVER THE PAGE AND COMPLETE THE REVERSE. THANK YOU.

Jan 2017

How many units of alcohol do you drink in one week? _____ Units

This is one unit of alcohol…

…and each of these is more than one unit

Please tick one of the following:

WHITE / British / Irish / Other
ASIAN or ASIAN BRITISH / Indian / Parkastani / Bangladeshi / Other
BLACK or BLACK BRITISH / African / Caribbean / Other
OTHER ETHNIC BACKGROUND / Chinese / Other
FIRST LANGUAGE / English / Other / Please Specify:

PLEASE NOTE: Your named GP is Dr Mark Deverell

.

As a patient of this practice you will have DrM Deverellas your named GP and he will have overall responsibility for the care and support that our surgery will provide you.

The named accountable GP will take lead responsibility for the coordination of all services required under the contract and ensure they are delivered to each of his patients where required.

This arrangement does not prevent you from making an appointment or seeing any doctor or nursein the surgery.

Thank you for completing this questionnaire. It will be of great help to us.

Jan 17

Please complete this form if you are registering a child that is under 5 years old

The Old Dispensary, 32 East Borough, Wimborne, Dorset, BH21 2AD

NOTIFICATION OF “UNDER 5’S” NEW PATIENTS FOR HEALTH VISITORS

TODAYS DATE …………………………..

CHILDS SURNAME …………………………………………………………………...

FORENAME ……………………………………………….……………

DATE OF BIRTH ………………………………………………

PARENTS NAME ……………………………………………………………..………………………….

NHS NO……………………………………

ADDRESS ………………………………………………………………………..……………………………………

POSTCODE……………………….

TEL NO …………………………………………MOBILE………………………………………….

DOCTOR: Dr M H Deverell

PREVIOUS ADDRESS ………………………………………………………………………………………….…

POSTCODE………………………

PREVIOUS GP ………………………………………………………………………………………………………………

ETHNIC ORIGIN ……………………………………………

PLACE OF BIRTH ……………………………………

OFFICIAL USE ONLY.

NOTIFICATION RECEIVED CONTACT INITIATED PATIENT SEEN

Jan 17

The Old Dispensary

Patient Participation Group

OurPatient Participation Groupis a way of encouraging patients to give their views about howThe Old Dispensary is doing. We would like to be able to find out the opinions of as many of our patients as possible and are asking if patients would provide their e-mail addresses so that we can makecontactby e-mail every now and then. Please would you indicate at the bottom of this form you how you would prefer to interact with us at the surgery.

Please fill in your name, e-mail details and preference of the way you would like to give your views at the bottom of this form and either post it in the repeat prescription/suggestion box inside the front door or hand it to one of our receptionists.

If you don’t have email but would like to participate, please complete your name and address details at the bottom of the form.

Your contact details will only be used for this purpose and kept safely.

In the coming months, we will be carrying out surveys to find out what patients think of our services and publishing the results. Your suggestions will help us to gather ideas for improvements or modifications to the services that we provide.

I would prefer my views to be obtained by:

Please tick all that apply

  1. Face to Face Meetings at the Surgery
  1. Being contacted periodically by the practice via email to be asked your opinion on certain matters
  1. Responding to Surveys sent out by the Practice via email

Name………………………………………………………………. Age……………….

Email Address……………………………………………………

Date……………………………………..

Jan 17

Dear Patient

Summary Care Record – your emergency care summary

The NHS in England is introducing the Summary Care Record, which will be used in emergency care. The record will contain information about any medicines you are taking, allergies you suffer from and any bad reactions to medicines you have had to ensure those caring for you have enough information to treat you safely.

Your Summary Care Record will be available to authorised healthcare staff providing your care anywhere in England, but they will ask your permission before they look at it. This means that if you have an accident or become ill, the doctors treating you will have immediate access to important information about your health.

Your GP practice is supporting Summary Care Records and as a patient you have a choice:

□Yes I would like a Summary Care Record –Please specify which type of Summary Care Record you would like created (please tick):

□Medications, allergies & adverse reactions ONLY

□Medications, allergies, adverse reactions AND additional information

□No I do not want a Summary Care Record – enclosed is an opt out form. Please complete the form and hand it to a member of the GP practice staff.

Signed:……………………………………. Date of Birth:…………………….

Print Name:……………………………….. Date:………………

If you need more time to make your choice you should let your GP Practice know.

You can access more information about Summary Care Records on the following link:-

You can choose not to have a Summary Care Record and you can change your mind at any time by informing your GP practice.

If you do nothing we will assume that you are happy with these changes and create a Summary Care Record for you. Children under 16 will automatically have a Summary Care Record created for them unless their parent or guardian chooses to opt them out. If you are the parent or guardian of a child under 16 and feel that they are old enough to understand, then you should make this information available to them.

Yours sincerely

The Old Dispensary

32 East Borough

Wimborne

Dorset

BH21 1PL

Tel: 01202 880786

Jan 17

OPT OUT FORM

Request for my clinical information to be withheld from the

Summary Care Record

If you DO NOT want a Summary Care Record please fill out the form and send it to your GP Practice

A. Please complete in BLOCK CAPITALS

Title ...... Surname / Family name ......

Forename(s)………………………………………………………………..

Address.……......

Postcode ...... Phone No ......

Date of birth ...... NHS Number (if known) ……………………………

Signature ...... Date……………………………..

B. If you are filling out this form on behalf of another person or a child, their GP practice will consider this request.

Please ensure you fill out their details in section A and your details in section B

Your name ......

Your Signature......

Relationship to patient ......

Date ......

What does it mean if I DO NOT have a Summary Care Record?

NHS healthcare staff caring for you may not be aware of your current medications, allergies you suffer from and any bad reactions to medicines you have had, in order to treat you safely in an emergency.

Your records will stay as they are now with information being shared by letter, email, fax or phone.

If you have any questions, or if you want to discuss your choices, please contact your GP practice.

Jan 17

THE OLD DISPENSARY

ARE YOU A CARER?

Do you look after someone who cannot fully care for themselves? A family member or friend who is unwell, disabled or frail? Please help us to help you by completing this form. Once you are added to our list of carers we will know about your busy life as a carer, which can affect your health.

YOUR DETAILS:

NAME
ADDRESS
POST CODE
TEL NO
DATE OF BIRTH
Any other information you would like to inform us of?

DETAILS OF THE PERSON YOU CARE FOR:

NAME
ADDRESS
(if different from above)
POST CODE
TEL NO
DATE OF BIRTH
RELATIONSHIP TO YOU
Are they registered at The Old Dispensary?

Would you like to be contacted by our ‘Carers Lead’? YES / NO

Jan 17

SURGERY USE: SCAN and CODE 918G