New Patient Registration V2 (2021)

Fields marked "REQUIRED" are compulsory. You should only send this form if you are sure that you are eligible to join this practice. Sending this form will NOT automatically register you with the surgery. Your details will be held at the surgery for a limited period of time. Once you have completed your form, please email ID documents to bhccg.clinicalstpeters@nhs.net. To become registered at St Peter’s Medical Centre please can you complete this Registration Form and produce proof of identification with name and current address. • Photographic ID e.g. passport, driving licence, bus pass AND • Proof of address in the form of an up to date utility bill, bank statement, Tenancy Agreement or Solicitors letter (dated within the last 3 months) • Birth Certificate (For registering children) If you are unable to provide any of the above documents, then please speak with a member of the reception team. Sending this form does NOT guarantee or even imply that you will be accepted onto the practice register.

Last Updated: 19/05/2021

Personal Details






















Your Previous GP Surgery

If you have never been on an NHS GP list, write 'none'




If you have come from abroad





Next of Kin/Dependants







Armed forces




Carer's details

If relevant, we will need consent from the person before we can record their details on your health records – please provide a signed letter from them including name, DOB, address and contact number.







Current Medication

If you are taking a repeat medication you will need to speak to a member of our pharmacy team


Electronic Prescribing

The Electronic Prescribing Service (EPS2) is now available for our patients which means we will be able to send prescriptions electronically direct to your Nominated Pharmacy. Please add your Nominated Pharmacy below


Past Medical History

Please tick yes or no to the following conditions














Family History

Please answer yes or no if any blood relatives have any of following health problems / diseases








Women ONLY







Blood pressure/height/weight/smoking status









Consent for Text (PLEASE READ BELOW)

• I acknowledge that the responsibility for checking my test results still rests with me. •I understand messages are sent via a secure facility over a public network to a personal phone. • I understand I can cancel the text message facility at any time.

Consent for Email communication (PLEASE READ BELOW)

• I acknowledge that the responsibility for checking my test results still rests with me • I acknowledge if I use a shared email address it is my responsibility to ensure any confidential information is safe. We will send you an automatic verification request via email – please follow instructions carefully by clicking link we send. You will need to answer some security questions. We cannot verify email manually.

Your Data Matters to the NHS

Information about your health and care helps us to improve your individual care, speed up diagnosis, plan your local services and research new treatments. In May 2018, the strict rules about how this data can and cannot be used were strengthened. The NHS is committed to keeping patient information safe and always being clear about how it is used. You can choose whether your confidential patient information is used for research and planning.

Summary Care Record (SCR)

If you are registered with a GP practice in England, you will already have a Summary Care Record (SCR), unless you have previously chosen not to have one. It will contain key information about the medicines you are taking, allergies you suffer from and any adverse reactions to medicines you have had in the past. Information about your healthcare may not be routinely shared across different healthcare organisations and systems. You may need to be treated by health and care professionals who do not know your medical history. Essential details about your healthcare can be difficult to remember, particularly when you are unwell or have complex care needs. Having a Summary Care Record can help by providing healthcare staff treating you with vital information from your health record. This will help the staff involved in your care make better and safer decisions about how best to treat you. You have a choice You have the choice of what information you would like to share and with whom. Authorised healthcare staff can only view your SCR with your permission. The information shared will solely be used for the benefit of your care. Your options are outlined below; please indicate your choice on the form. Express consent for medication, allergies and adverse reactions only: You wish to share information about medication, allergies for adverse reactions only. Express consent for medication, allergies, adverse reactions and additional information: You wish to share information about medication, allergies for adverse reactions and further medical information that includes: your illnesses and health problems, operations and vaccinations you have had in the past, how you would like to be treated (such as where you would prefer to receive care), what support you might need and who should be contacted for more information about you. Express dissent for Summary Care Record (opt out): Select this option, if you DO NOT want any information shared with other healthcare professionals involved in your care. If you chose not to complete this consent form, a core Summary Care Record (SCR) will be created for you, which will contain only medications, allergies and adverse reactions. Once you have completed the consent form, please return it to your GP practice. You are free to change your decision at any time by informing your GP practice.

Additional Information: How you describe yourself?

We want to make sure everyone is treated fairly and equally. That is why we ask you for this additional information. All answers are confidential. It will be included in your medical record but we will not share the information you give us with anyone outside the NHS. We will use the information you provide to improve your care and anonymously to help make decisions about improving services.



Sexual Orintation


Religion


Disability



Alcohol

Alcohol use can affect your health and can interfere with certain medications and treatments. Your answers will remain confidential so please be honest.












Whooley Questions

If you answer ‘yes’ to these questions then you could be suffering from depression. If you would like help with this you can self-refer to the Brighton Wellbeing Service for talking therapy by visiting www.brightonandhovewellbeing.org, by calling them on 0300 002 0060 or by making an appointment with a GP or Nurse at the surgery. If you feel need urgent help as a result of a mental health crisis then you can contact the mental health rapid response service by phoning 0300 304 0078.


Authorisation






ID documents

To become registered at St Peter’s Medical Centre please can you complete this Registration Form. You do not need to produce any proof of ID unless you are requesting to use our online services for appointment booking, requesting repeat prescriptions and access to your medical records. The proof of ID should have your name and current address. • Photographic ID e.g. passport, driving licence, bus pass AND • Proof of address in the form of an up to date utility bill, bank statement, Tenancy Agreement or Solicitors letter (dated within the last 3 months) • Birth Certificate (For registering children) If you are unable to provide any of the above documents, then please speak with a member of the reception team.