Adult Registration - Clarendon Medical Practice

All new patients will be asked to produce a document to prove personal and residential identification when registering:

This should be one of the following:-

Valid Driving Licence
Valid Passport

In addition, proof of address:-

Local Authority Rental agreement
Paid Utility Bills under 3 months old
Bank Statements under 3 months old

If you are homeless and wish to register with us, please speak to our Reception Manager who may be able to assist with this.

Non-urgent advice: Please note

We do not routinely offer New Patient Medicals, but if you are over 70 or have a Chronic Long Term Disease such as Asthma/Diabetes etc. and wish to have one, please ask Reception.

Online Registration

Name

Title First Last

Address

Street Address Address Line 2 City Postcode

Place of birth

Date of birth

Day

Month

Year

Contact Number

NHS Number (if known) Optional

Enter Email Confirm Email

Marital Status

Occupation

Consent given for communication by:

Email Optional

SMS Text Messaging Optional

Is your gender identity the same as the gender you were assigned at birth?

Yes

Which of the following best describes how you think of yourself

Please nominate a pharmacy for prescriptions to be sent to

Nominate Pharmacy Address

Street Address Address Line 2 City Postcode

Are you from abroad?

Yes

Date entered UK

MM slash DD slash YYYY

Date of leaving UK (if applicable) Optional

MM slash DD slash YYYY

Are you an Asylum Seeker?

Yes

Are you a military veteran?

Yes

Ethnic origin

First Language

Do you need an Interpreter?

Yes

General History

Do you have any disabilities we should be aware of?

Yes

Please specify

Have you had any serious illnesses /operations /X-rays or similar tests?

Yes

Please specify

If you have any recent or ongoing problems, you may need to see the GP or nurse

Are you taking any medicines?

Yes

What medicines are you taking?

Please bring in your current repeat slip if you have one.

If you are on medication, your previous GP is able to provide you with a one month supply until your registration with us is completed.

Are you currently under investigation or being referred for anything?

Yes

Please specify

Have you any allergies to medicines or anything else?

Yes

Please specify

What exercise do you do per week?

Which of the following options best describes your sexual orientation?

Please specify

Next of Kin

Name of Next of Kin

First Last

Next of Kin Contact Number

Carers

Are you a carer?

Yes

Do you have a carer?

Yes

Your Carer's Name

First Last

Your Carer's Contact Number

Who do you care for?

First Last

Their Contact Number

Do you have any children under 18 who live with you?

Yes

Are they registered/registering with us?

Yes

We strongly advise that families with children should all be registered with the same practice

Alcohol Consumption & Smoking Status

How often do you have a drink containing alcohol?

How many alcoholic drinks do you have on a typical day?

How often do you have 6 or more drinks on one occasion?

Do you smoke?

How much tobacco or cigarettes do you smoke per day?

Smoking is bad for your health. If you would like to give up smoking, please book an appointment with our Assistant Practitioner.

Date you gave up

Month

Day

Year

Vaccinations

Which vaccinations have you had?

Diphtheria

Polio

Measles/Mumps/Rubella

Tetanus

BCG (TB)

Shingles

Influenza

COVID

Dates of when you had each vaccination

Your Details

Height (cm)

Weight (kg)

If you would like help in losing weight or advice on healthy eating or exercise, please ask for an appointment

Female Patients

Do you have children?

Yes Optional

No Optional

How many?

Are you currently, or think you may be, pregnant?

Yes Optional

No Optional

Which method of contraception (if any) are you using at present? Optional

When/where did you last have a smear?

Day Optional

Month Optional

Year Optional

What was the result (if known)? Optional

For patients aged 85 or over

These are to help us assess if you may need additional clinical input.

What is your age? Optional

In general, do you have any health problems that require you to limit your activities?

Yes Optional

No Optional

Do you need someone to help you on a regular basis?

Yes Optional

No Optional

In general, do you have any health problems that require you to stay at home?

Yes Optional

No Optional

In case of need, can you count on someone close to you?

Yes Optional

No Optional

Do you regularly use a stick, walker or wheelchair to get about?

Yes Optional

No Optional

Consent

I confirm that the information given is true to the best of my knowledge Optional

Patient Consent Form

Consent to hold, process and share manual and electronic records and data in accordance with the Data Protection Act 2018, the Caldicott Report, and other relevant Information Governance legislation.

When you are registered at the practice, your details will be shared, as appropriate:

· With members of the practice health care team

· With other healthcare professionals involved in my care

· For the purposes of practice administration

I give my informed consent for Clarendon Surgery & The Angel Medical Centre to hold, process and share my personal and medical records, manually and electronically, as outlined below:-

Locally for the purposes of the Local Shared Electronic Record) and Hub for my direct health care

Yes

Nationally for the purposes of National Shared Electronic Record (SCR) for my direct health care

Yes

Nationally for the purposes of improving and planning the health and care of current and future generations (indirect health care)

Yes

If you have any concerns regarding how your information will be used by the practice and others, please see our Practice Confidentiality Statement.

Patient’s name (if consenting for a child under 13)

First Optional Last Optional

Your Name:

First Optional Last Optional

Please note – We use companies called Iplato & AccuRx to send text reminders and health care invitations to patients (for example, appointment reminders/ flu vaccination invites). We have gained approval from Salford CCG to use these companies and we are confident your data is secure. If you have any concerns regarding this, please speak to the Practice Manager

By providing your contact details, you are consenting to us using them to contact you by post, telephone, email or SMS (text).

We do not share your data for the purposes of education, research, audit or administration without your express consent (i.e. we would ask you every time for permission before doing this). The only exception to this would be where the data was anonymised, i.e. not identifiable back to you.

Your Appointments & Prescriptions Online

You can now book, cancel and view your appointments, as well as ordering your repeat medication online. This service is provided through our Clinical Software Supplier (Emis), and is called Patient Access.

If you are interested in this service, you will need to complete the registration Form below and come to the surgery with an appropriate form of photo ID (such as a Passport or Driving License). Please note: each family member 13 and over will need to visit the surgery with their own Photo ID.

Once registered, we will send you an e-mail within 28 days, with information that will enable you to create a Patient Access account and link it to the surgery.

I wish to register for Patient Access

Name

First Optional Last Optional

Date of birth

Day Optional

Month Optional

Year Optional

Parents / guardians can register on behalf of their children under 13. However, when a child turns 13, they will be automatically de-registered and written to explaining why. They will then be able to re-register using their own contact details, or should they choose to, their parent / guardian’s email address.

Enter Email Optional Confirm Email Optional

Contact Number Optional

By providing your email address / mobile phone number, you consent to the surgery using it to communicate with you regarding your healthcare. It will not be shared with any other companies, and you can opt out of Patient Access and communication by email / SMS at any time by contacting the surgery.

The surgery does not recommend that patients use a shared email address / mobile phone number – you will be sent appointment booking and prescription confirmation emails, which may be confidential to the individual. By choosing to use a shared email address / mobile phone number, you confirm that you are aware of this issue and accept the consequences. For more information, please contact the surgery.

Please remember it is your responsibility to keep us informed if your contact details change.

Untitled

First Choice Optional

Second Choice Optional

Third Choice Optional

Untitled

First Choice Optional

Second Choice Optional

Third Choice Optional

Non-urgent advice: Please note

Online Registration

General History

Next of Kin

Carers

Alcohol Consumption & Smoking Status

Vaccinations

Your Details

Female Patients

For patients aged 85 or over

Patient Consent Form

Your Appointments & Prescriptions Online

I wish to register for Patient Access

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