Patient's Details

    Title

    Gender

    Given Name

    Family Name

    Previous Surnames (If any)

    Middle Name(s)

    Known as/Preferred Name

    Date of birth

    NHS Number

    Marital Status

    Town and country of birth

    What is your Ethnicity

    What is your first language?

    Do you require a translator?

    Your current Address

    House Name/Flat Number

    Street/Road name

    Town/City

    Post Code

    Your Contact Details

    Home Phone

    Mobile Phone

    Work Phone

    Email

    Preferred communication method

    Are you happy for us to contact you via these methods for appointment reminders and clinical services?

    Text message:

    Email:


    Complete this section if you live in another EEA country, or have moved to the UK to study or retire, or if you live in the UK but work in another EEA member state.


    Please DO NOT complete this section if you have an EHIC issued by the UK or are a UK resident SKIP THIS STEP

    NON-UK EUROPEAN HEALTH INSURANCE CARD (EHIC), PROVISIONAL REPLACEMENT CERTIFICATE (PRC) DETAILS and S1 FORMS

    Do you have a non-UK EHIC or PRC?

    EHIC Card

    If YES, Please enter details from your EHCI or PRC below:

    Country code:

    Name:

    Given Names:

    Date of birth

    Personal Identification Number:

    Identification Number of the Institution:

    Identification Number of the Card:

    Expiry date:

    PRC Validity period - a) From:

    PRC Validity period - a) To:

    Please tick if you have an S1 (eg. you are retiring to the UK or you have been posted here by your employer for work or you live in the UK but work in another EEA member state). Please give your S1 form to the practice staff.

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

    By using your EHIC or PRC for NHS treatment costs your EHIC or PRC data and GP appointment data will be shared with NHS secondary care (hospitals) and NHS Digital solely for the purposes of cost recovery. Your clinical data will not be shared in the cost recovery process.
    Your EHIC, PRC or S1 information will be shared with The Department for Work and Pensions for the purpose of recovering your NHS costs from your home country.

    Anybody in England can register with a GP practice and receive free medical care from that practice.

    However, if you are not ‘ordinarily resident’ in the UK you may have to pay for NHS treatment outside of the GP practice. Being ordinarily resident broadly means living lawfully in the UK on a properly settled basis for the time being. In most cases, nationals of countries outside the European Economic Area must also have the status of ‘indefinite leave to remain’ in the UK.

    Some services, such as diagnostic tests of suspected infectious diseases and any treatment of those diseases are free of charge to all people, while some groups who are not ordinarily resident here are exempt from all treatment charges.

    More information on ordinary residence, exemptions and paying for NHS services can be found in the Visitor and Migrant patient leaflet, available from your GP practice.

    You may be asked to provide proof of entitlement in order to receive free NHS treatment outside of the GP practice, otherwise you may be charged for your treatment. Even if you have to pay for a service, you will always be provided with any immediately necessary or urgent treatment, regardless of advance payment.

    The information you give on this form will be used to assist in identifying your chargeable status, and may be shared, including with NHS secondary care organisations (e.g. hospitals) and NHS Digital, for the purposes of validation, invoicing and cost recovery. You may be contacted on behalf of the NHS to confirm any details you have provided.

    Please tick one of the following boxes

    a) I understand that I may need to pay for NHS treatment outside of the GP practiceb) I understand I have a valid exemption from paying for NHS treatment outside of the GP practice. This includes for example, an EHIC, or payment of the Immigration Health Charge (“the Surcharge”), when accompanied by a valid visa. I can provide documents to support this when requestedc) I do not know my chargeable status


    Previous details

    Previous address

    House Name/Flat Number

    Street/Road name

    Town/City

    Post Code

    Name and address of previous GP

    **If you were not born in the UK**

    Country of Birth

    Town of Birth

    Date of entry to U.K

    **If you are returning from abroad**

    Date you left the UK

    Date you returned to the UK

    If you are returning from the Armed Forces

    Address before enlisting

    Service/Personnel number

    Enlistment date


    Next of Kin

    Next of kin title

    Next of kin first name

    Next of kin last name

    What is this person's relationship to you?

    Next of Kin Telephone Number (must be a British contact number)

    Is your next of kin registered/or will be registering at Elborough Street Surgery?

    Medical History

    Your Gender (Please tick the term that best reflects how you identify)


    Are you trans/is your gender different to the one you were given at birth?

    Your Sexual Orientation (Please tick the background that best reflects your sexual orientation)

    What is your current smoking status?

    Diabetes YesNo

    Date of Diabetes Diagnosis

    High Blood Pressure YesNo

    Date of High Blood Pressure diagnosis

    Heart Attack YesNo

    Date of Heart Attack diagnosis

    Asthma YesNo

    Date of Asthma diagnosis

    Stroke YesNo

    Date of Stroke diagnosis

    Cancer YesNo

    Date of Cancer diagnosis

    Type of Cancer? (e.g. bowel cancer, breast cancer etc)

    Mental Illness YesNo

    Date of Mental Illness diagnosis

    Disability YesNo

    Type of Disability

    Other

    Are you a housebound patient? (This means someone who is unable to leave their home environment due to a physical or psychological illness) YesNo



    Medications

    Please provide details of any medications you are currently being prescribed (or leave blank if you you are not on any medication)

    Current/Regular Medication Name:

    Medication Reason:

    Eg: Asthma, Diabetes etc

    Current/Regular Medication Name:

    Medication Reason:

    Eg: Asthma, Diabetes etc

    Current/Regular Medication Name:

    Medication Reason:

    Eg: Asthma, Diabetes etc

    Add any additional current/regular medications here:

    In an effort to support the NHS Paper Switch-Off Programme (PSO) we will no longer be printing prescriptions. Please ensure that you select a pharmacy below to have any future prescriptions sent through to electronically.*

    Allergies
    Please provide details of any allergies that you have (or leave blank if you have no allergies)

    Name of Allergy:

    What happens? What is the reaction?

    Name of Allergy:

    What happens? What is the reaction?

    Add any additional allergies here:


    Family History

    Please enter details here if there is any relevant medical history in your family (or leave blank if there is none)

    High Blood Pressure

    Diabetes

    Mental Illness

    Stroke

    Cancer

    Heart Attack

    Asthma


    Carers
    Please provide details if you are a Carer, are Cared for, or are on an disability register (continue to the next question if not)

    Are you A CARER FOR a friend or a relative?

    Are you CARED FOR by a friend or a relative?


    Summary Care Record

    The Summary Care Record (SCR) is an electronic record of important patient information, created from GP medical records. It can be seen and used by authorised staff in other areas of the health and care system involved in your direct care.

    Access to SCR information means that care in other settings is safer, reducing the risk of prescribing errors. It also helps avoid delays to urgent care.

    As standard, the SCR holds:

    • Your name, address, date of birth and NHS number
    • Your current medication
    • Your allergies and details of any previous bad reactions to medicines

    You can also choose to share an enhanced record. This is particularly useful if you are elderly, or have complex or long term conditions. The enhanced SCR holds:

    • Significant medical history (past and present)
    • Reason for medications
    • Anticipatory care information (such as information about the management of long term conditions)
    • End of life care information
    • Immunisations

    Summary Care Record Consent*

    Alcohol Consumption

    Alcohol Consumption

    Alcohol Scoring System

    Using the scoring system above, please score yourself between 0-4 for the following questions. If you do not drink, please enter 0 in all the boxes.

    How often have you had 6 or more units if female, or 8 or more if male, on a single occasion in the last year?

    How often during the last year have you been unable to remember what happened the night before because you had been drinking?

    Has a relative or friend, doctor or other health worker been concerned about your drinking or suggested that you cut down? YesNo


    PATIENT DECLARATION

    Online Access

    If you are 16+ and speak English fluently, you have the option to register for Patient Access allowing you to book and cancel routine GP appointments online, view blood test results and view your consultations and immunisation history online. If you do not speak English and require an interpreter for appointments, you will be unable to make appointments online. Please contact us to book appointments.

    (Required)

    Please specify if you would like to join Patient Access:

    To register for patient access please complete the application form below. Once we’ve received your application form we will then email you your login details.

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

    1. Booking appointments YesNo
    2. Requesting repeat prescriptions YesNo
    3. Accessing my medical record YesNo

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

    (All of these fields are required)
    1. I will be responsible for the security of the information that I see or download YesNo
    2. If I choose to share my information with anyone else, this is at my own risk YesNo
    3. If I suspect that my account has been accessed by someone without my agreement, I will contact the practice immediately
    4. If I see information in my record that is not about me or is inaccurate, I will contact the practice as soon as possible YesNo
    5. If I think that I may come under pressure to give access to someone else unwillingly I will contact the practice as soon as possible. YesNo

    Patient Acceptance

    (Required)

    [acceptance* declaration-acceptance] 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. [/acceptance]

    Identification

    Please upload a copy of your driving licence, passport or ID card so as we can verify your identity.

    (File types accepted .png, .jpg and .pdf. Maximum file size 5mb)

    Signature

    (Required)

    Who is signing

    Please sign in the box below using your mouse or on the screen of your tablet.

    (Required)

    Print name of signatory:

    (Required)

    By clicking submit you confirm that you have read and agreed our terms of service and terms of service and privacy policy

    (Required)