Next of kin - please give the names, addresses, contact numbers abd relationship to your next of kin
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Would you like to be provided with an ACP booklet (Advance Care Planning)? Advance Care Planning is a process that enables individuals to make plans about their future health care.
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Summary Care Record. Your records will automatically be coded for an Enhanced Summary Care Record. This is a short summary of your GP medical records. It tells other health and care staff who care for you about the medicines you take and your allergies. It means they can give you better care if you need health care away from your usual doctor's surgery: for example, in an emergency, when you're on holiday, when your surgery is closed, at out-patient clinics or when you visit a pharmacy. If you do not want a summary care record, please ask at reception for an OPT OUT form and indicate here.
Third party access - In the Practice we aim to provide you with the highest quality of healthcare. To do this we must keep records about you, your health and the care we have provided or plan to provide to you. Everyone working for the nhs has a legal duty to keep information about you confidential. if you would like a family member or carer to have access to your medical records on your behalf, we need to keep their contact details on your records. The person you nominate must be happy to have their details recorded in your medical records. If you wish to nominate someone for this reason please provide their details below and indicate that you consent to this and date. it
We recommend patients provide identification when registering at the practice but we can still register you without it. However, you won't be able to access our online services without proof of identification. We do recommend patients sign up for online services. Please indicate below if you would like to sign up for online services for the following:
What is your first spoken language?
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Do you require an interpreter?
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Please give your height and weight
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Do you smoke cigarettes?
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Do you smoke any of the following?
personal medical history. Please select any that are relevant.
For previous question, please indicate date of diagnosis or list any other conditions.
Family history - please indicate if any of your family suffers from:
For previous question, if any of these conditions apply, please give relationship to you and their age.
Medication - if you are taking regular medication from your previous GP you will need to book an appointment before our GPs can issue this. Please allow yourself plenty of time so you do not run out of medication and bring along any previous prescription requests or medication with you to the appointment. Please note we do NOT accept prescription requests over the phone unless you are housebound and prescriptions take 48-72 hours to be processed. Please list any over the counter medication used regularly
Allergies - please advise of any known allergies
New patient health check - would you like an appointment for a health check with our HCA (Healthcare Assistant)? You can choose at the appointment to have a quick and simple test for HIV if you wish to do so.
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Carers - are you a carer to someone else?
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Is there someone you rely on for your care?
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Would you like to be referred to Carers MK?
Women only - have you had a total hysterectomy and therefore do not require smear testing?
Alcohol - for men how often have you had 8 or more units on a single occasion in the last year? For women, how many times have you had 6 or more units on a single occasion in the last year?
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how often during the last year have you failed to do what was normally expected from you because of your drinking?
communication - we want to make sure you can read and understand the information we send you. If you find it hard to read letters or if you need someone to support you at appointments, please let us know.
How would you prefer us to communicate with you?
Is there any other communication support we should provide for you?
do you live in a care home?
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If you are homeless or at risk of homelessness, please complete the information below
details of when you expect to become homeless
homeless or risk of homeless current living situation, are you:
Homeless or risk of homeless current accomodation
Consent. I consent to the practice contacting me by text message and/or email for the purposes of health promotion and for appointment reminders. I acknowledge that appointment reminders by text and/or email are an additional service and that these may not take place on all or any occation and that the responsibility of attending appointments or cancelling them still rests with me. I can cancel the text and/or email message facility at any time. Text messages are generated using a secure facility, however I understand that they are sent over a public network onto a personal telephone and as such may not be secure. However, the practice will not transmit any information which would enable an individual patient to be identified. I agree to advise the practice if my email address changes and also if my mobile telephone number changes or if this is no longer in my possession. The practice does not share mobile phone contact details or email addresses with any external non-nhs organisation. Your medical records may be used for financial or clinical audit, post payment verification checks, medical research or education purposes.
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I confirm that the information I have given is accurate to the best of my knowledge and that I live within the practice boundary catchment area as detailed on the NPMC website and confirm that I have read the contract of care on the new patients page of the website