Access To Records « Hickings Lane Medical Centre

Patient's Details
Registration For:*
Name*
Title First Name Middle Name(s) Surname
Previous Surname
Date of Birth*
DD slash MM slash YYYY
Gender*
NHS Number

Find your NHS number
Town of Birth*
Country of Birth*
Current Home Address*
Address Line 1 Address Line 2 City County Postal Code Country
Email Address*
Enter Email Confirm Email
Home Phone Number*
Mobile Phone Number*
Work Phone Number
Can we contact you by text?*
- Yes
- No
Please be aware if you say “NO” you will not receive appointment reminders via text
Can we contact you by email?*
- Yes
- No
Marital Status:*
- Single
- Married
- Common Law Partnership
- Divorced
- Separated
- Widowed
Employment Status:*
- Employed
- House Husband
- Housewife
- Self-Employed
- Internaltional Student
- Unemployed
Occupation*
Contraception*
- Uses Contraception
- Contraception not Needed
Pregnancy*
- Currently Pregnant
- Possibly Pregnant
- Not Pregnant
Pregnancy Expected Due Date*
DD slash MM slash YYYY
Current School Address*
School Name Address Line 2 City County Postal Code Country

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Healthy Family Team
Hello,

Welcome to the Stapleford Area.

The Health Family Team are based at the following address:

Nottinghamshire Healthcare (NHS foundation Trust)

Stapleford Care Centre

Church Street

Stapleford

Nottingham

NG9 8DB

Please help us by completing the form below. If you would like to see a member of the Healthy Family Team urgently please contact us on 0115 883 55 00.

Best Wishes

Healthy Family Team
Have you already completed this section for all Children under 5 on a previous registration with us?*
- Yes
- No
Number of Children Under 5?*
Name of Child 1*
First Name Surname DOB (dd/mm/yyyy)
Name of Child 2*
First Name Surname DOB (dd/mm/yyyy)
Name of Child 3*
First Name Surname DOB (dd/mm/yyyy)
Name of Child 4*
First Name Surname DOB (dd/mm/yyyy)
New Address*
Address Line 1 Address Line 2 City County Postal Code Country
Current School Address*
School Name Address Line 2 City County Postal Code Country
Previouse Address*
Address Line 1 Address Line 2 City County Postal Code Country
Address of previous GP practice
Address Line 1 Address Line 2 City County Postal Code
First Language:*
Date*
DD slash MM slash YYYY

Carers
Do you have a carer?*
- Yes
- No
Name of carer:*
Title First Name Surname
Phone number of carer:*
What relationship is the person that cares for you?*
Do you give us permission to discuss your medical record with your carer?*
- Yes
- No
Are you a carer for someone?*
- Yes
- No
What relationship is the person you care for?*

Lifestyle
Height*
Please enter a number less than or equal to 3.00.
Weight*
Please enter a number less than or equal to 100.
Please state how much exercise and what type of exercise you do per week:
e-Cigarette Status:*
- Current User of e-Cigarettes
- Ex User of e-Cigarettes
- No
Smoking Status:*
- Current Smoker
- Ex Smoker
- Never Smoked
How many do you smoke per day?*
Are you interested in advice on how to quit?*
- Yes
- No
Help to Quite Smoking
Please visit Your Health Notts for information on how to stop smoking. You will also receive a text message with the above link once registered as a patient.
How many did you smoke per day?*
When did you stop?*
DD slash MM slash YYYY

Estimated Date

Allergies
Do you have any allergies?*
- Yes
- No
Please specify what you are allergic to, what happens and when you had your first reaction:*
Medication
Are you on current medication (repeat)?*
- Yes
- No
Please attach a repeat slip for any repeat medications you are currently taking
Accepted file types: jpg, png, pdf, Max. file size: 64 MB.
Current Medication:
Please list If you cannot attach a repeat slip.
If you would like to nominate a pharmacy to send your prescriptions electronically to please state here:

Summary Care Record
NHS England has introduced the Summary Care Record to be used in Emergency care.
The record will contain information about any medicines you are taking, allergies you suffer from & any bad reactions to medicines you have had to ensure those caring for you have enough information to treat you safely.
More details concerning the Summary Care Record and what it means to you can be found here.
Do you consent to the shared NHS Summary Care Record (SCR)?*
- Yes
- No
Summary Care Record Opt Out
Your Summary Care Record contains important information from the record held by your GP practice and includes details of any medicines you are taking, any allergies you suffer from and any bad reactions to medicines that you have previously experienced.
Your Summary Care Record also includes your name, address, date of birth and your unique NHS Number to help identify you correctly.
As part of a mandatory national programme each GP Practice had to make a summary care record for each patient by March 2015 (unless the patient has already opted out).
You can choose to opt out of this scheme at any time.
If you wish to opt out of the Summary Care Record scheme please complete the following form.
Section A
If you are filling this form on behalf of another person or child please ensure you fill their details in section A and your details in section B.
Name*
Title First Name Surname
Address*
Street Address Address Line 2 City County Postal Code
Phone Number*
Email
Section B
If you are filling this form on behalf of another person or child please ensure you fill their details in section A and your details in section B.
Name*
Title First Name Surname
Relationship to Patient:*
Signature*
Date*
DD slash MM slash YYYY

Permission to Share Records
Our Clinical system, SystmOne, is used by other health teams in Nottinghamshire who may be involved in your care. (For example: Urgent Care Centres, Podiatry, Physiotherapy, Child Health, Out of Hours etc.)
We need to know that you are happy to consent to us sharing your information that is held on our computer system.
This helps to deliver better and safer care for you.
Click here for more info on Sharing your GP record.
Please indicate your preference below:
Sharing Out - This controls whether your full electronic patient record can be shared with other NHS Care Services where you are treated. Please record your preference.*
- Yes
- No
Sharing In - This controls whether you agree for this practic e to view information you've agreed to share at other NHS Care Services. Please record your preference.*
- Yes
- No
Please note that you can change your mind at any time by informing us in writing You can also request for individual entries in your record here to be marked as 'Private'. These entries are not then shared with the other health teams even if you chose to 'Share Out'.
What happens to my information?
Personal and medical information about patients registered at this practice are primarily kept electronically, although some is kept in paper form.
Some information will be sent to hospital consultants and other health professionals to whom you are referred by your GP in order to provide continued healthcare and obtain treatment for you.

We sometimes use accredited suppliers for our communication with you, for example when we send recall letters for review clinics or medication reviews.
All suppliers we use are checked carefully to ensure they comply with strict confidentiality protocols.

To ensure the security of all patient information, all staff that has access to your records is covered by confidentiality clauses in their contracts and the Data Protection Act and the Freedom of Information Act.
Our guiding principle is that we hold your records in strict confidence.
Consent*
I certify that the information I have provided is correct and consent to my personal and medical information being used as stated above.
Signature*
Date*
DD slash MM slash YYYY

Online Services
You can register for online services to provide access to appointment booking, repeat prescription ordering and some sections of your medical record via the internet.
For more info please visit NHS App.

If you require access to online services for a child, please ask reception about our Proxy Access Protocol.
Would you like access to Online Services?*
- Yes
- No
Download NHS App
In order to register for online services please download the NHS App. Photo ID is required to register for this service.
If you require access to online services for a child (under 13), please ask reception about our Proxy Access Protocol.

Your Named General Practitioner
You may be aware that practices are required to provide all their patients with a named GP who will have overall responsibility for the care and support that our surgery provides to them.

As one of our patients, Dr John Doddy will be your named GP.

They will have overall responsibility for the care and support that our surgery provides to you. This does not prevent you from seeing any GP in the practice as you currently do.

You do not need to take any further action, but if you have any questions, or wish to discuss this further with us, please contact us on 0115 9395555.

NHS Organ Donor Registration
Organ donations in England has changed to an opt out system for most adults.

You still have a choice whether or not you want to become an organ donor.

We will always ask your family to support your decision. So whatever you choose, it's really important that you let them know.
Please visit www.organdonation.nhs.uk or call 0300 123 23 23 for more info.
Would you like join the NHS Organ Donor Register?*
- Yes
- No
To opt-out (if you're aged 18+) please visit www.organdonation.nhs.uk or call 0300 123 23 23.
I want to register my details on the NHS Organ Donor Register as someone whose organs/tissue may be used for transplantation after my death.*
- Any of my organs and tissue
- Kidneys
- Heart
- Liver
- Corneas
- Lungs
- Pancreas
Signature confirming my consent to join the NHS Organ Donor Register*
Date*
DD slash MM slash YYYY

NHS Blood Donor Registration
All blood types are needed, especially O negative and B negative. For more info please visit www.blood.co.uk or call 0300 123 23 23.
Would you like join the NHS Blood Donor Register?*
- Yes
- No
- Already on it
Have you have given blood in the last 3 years?*
- Yes
- No
My preferred address for donation is:
Signature confirming my consent to join the NHS Blood Donor Register*
Date*
DD slash MM slash YYYY

Proof of Identity/Address
In order to register, you will need to upload one of the following documents from Group A & B.
Proof of Identity Photo ID (Group A)*
Max. file size: 64 MB.
- a Passport
- a UK driving licence (full or provisional)
- a European driving licence (full)
- a European national identity card
Proof of Identity ID (Group A)*
Max. file size: 64 MB.
- a Passport
- a Birth certificate
- a European national identity card
Proof of Address (Group B)*
Max. file size: 64 MB.
- a recent utilities bill
- a recent council tax bill
- a recent bank statement
Proof of Address (Group B)*
Max. file size: 64 MB.
- a nursery/school letter
- a recent utilities bill
- a recent council tax bill
- a recent bank statement
Authorised Signature
Form completed by:*
- Patient
- On behalf of patient
Name*
First Name Surname
Relationship*
Consent*
I declare that the information I give on this form is correct and complete. I understand that if it is not correct, appropriate action may be taken against me.
Signature of patient*
Signature on behalf of patient*
Date*
DD slash MM slash YYYY
CAPTCHA
Name
This field is for validation purposes and should be left unchanged.

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Getting through on the phone
Speaking to a doctor on the phone
Speaking to a nurse on the phone
Obtaining test results by phone

	Very good	Good	Average	Poor	Very poor
Giving you enough time
Asking about your symptoms
Listening to you
Explaining tests & treatment
Involving you in decisions about your care
Treating you with care and concern
Taking your problems seriously

	Very good	Good	Average	Poor	Very poor
Giving you enough time
Asking about your symptoms
Listening to you
Explaining tests & treatment
Involving you in decisions about your care
Treating you with care and concern
Taking your problems seriously

Hickings Lane Medical Centre

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Patient's Details

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Healthy Family Team

Ethnicity

Emergency Contact

Previous Details

If you are from abroad

If you are returning from abroad

Supplementary Questions

Non-UK European Health Insurance Card (EHIC), Provisional Replacement Certificate (PRC) Details and S1 Form

How will your EHIC/PRC/S1 data be used?

Carers

Were you ever registered with an Armed Forces GP

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Lifestyle

Help to Quite Smoking

Alcohol Consumption

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This is one unit of alcohol:

And each one of these, is more than one unit:

Medical History

Allergies

Medication

Summary Care Record

Summary Care Record Opt Out

Section A

Section B

Permission to Share Records

What happens to my information?

Online Services

Download NHS App

Your Named General Practitioner

NHS Organ Donor Registration

NHS Blood Donor Registration

Proof of Identity/Address

Authorised Signature

Patient Participation Group

Patient Survey

Friends and Family Test