DRS  HUTSON, CHANDRAN& DUNCAN 
TREETON MEDICAL CENTRE, 10 ARUNDEL STREET,
TREETON, ROTHERHAM, S60 5PW

ADDITIONAL PATIENT REGISTRATION DETAILS AND INFORMATION

Please complete this form in order for you to be registered as a patient at the surgery.  

Name………………………………………  D.O.B………………………………………………………..
What is your Ethnicity? Eg. White. Black. Asian. Chinese. Mixed. Other…....................................................
What is your Primary language i.e English, Spanish etc. ……………………………………………………..
Place of Birth...................................................................
ILLNESSES, ACCIDENT or OPERATIONS
Please list all serious illnesses, accidents, hospital admissions or operations, with dates.
Please also list any present illnesses which you have. Eg. Asthma, Heart Disease, Diabetes

										

PLEASE LIST PRESENT MEDICINES AND ALLERGIES

How much alcohol do you drink in a week? ...........................................

Do you currently or have you ever smoked? If so please give details………………………..

FAMILY HISTORY
Do you or any of your family or close relations have (or have had) any of the following illnesses or conditions?
                                         Yes or No                                                          Yes or No                                
Diabetes                           ………….              Asthma                              …………..   
Glaucoma                         .…………              High Blood Pressure         …………..    
Heart attack                      .…………              Breast Cancer                    …………..   
Stroke                               ………….              Bowel Cancer                    ………….                     

Are you a carer for any relative/friend?   YES/NO.  If so please ask at reception for a carers’ leaflet.

P.T.O

Nominated Pharmacy:  

Would like to nominate a pharmacy for your prescription to be sent electronically to this chemist for collection, please specify pharmacy of choice:

  ………………………………………………………………………..

SMS Consent

If you have provided a mobile telephone number do you give your consent for the surgery to send SMS messages?   
Yes                 No

Please keep your contact details up to date to ensure we can contact you if required.  Thank you!

Named Accountable GP

The practice is required by the government under the terms of the latest GP contract to allocate all patients a named accountable GP.  Your Named GP will be Dr Duncan.  If you wish to be told the name of your named GP, please ask the receptionists when you are next in the surgery.

Having a named GP does not prevent you seeing any other doctor in the practice.
Your named GP will not be available at all times and if your needs are urgent, you may need to discuss them with an alternative doctor.

Summary Care Record

A summary care record will be created for you that will ensure that anyone treating you has basic but important information about you especially when care is unplanned, urgent or during the evenings and weekend.   The information accessible to a health professional will be medication and allergies.  If you wish opt out of this process please ask at reception for a form otherwise this will be automatically created for you.    				

Accessibility Standard

The Accessible Information Standard aims to ensure that people who have a disability or sensory loss receive information that they can access and understand, for example in large print, braille or via email, and professional communication support if they need it, for example from a British Sign Language interpreter
Communication:  Do you have any communication needs relating to a disability, impairment or sensory loss?   Please give details where possible or alternatively discuss this at your New Registration Appointment.

I CONFIRM THAT THE ABOVE INFORMATION TO BE TRUE AND COMPLETE TO MY KNOWLEDGE.

SIGNED……………………………………..	DATE………………………………………..

FOR SURGERY COMPLETION ONLY

New registration medical booked, date and time ……………………………….Acceptance Date…………………………………….
ID seen …………………………………………   Form Check by …………………………………………………………………….
Registered by………………………………………………….

			

			
New patient letter

Dear Patient

Summary Care Record – your emergency care summary 

The NHS in England is introducing the Summary Care Record, which will be used in emergency care. 

The record will contain information about any medicines you are taking, allergies you suffer from and any bad reactions to medicines you have had to ensure those caring for you have enough information to treat you safely. 

Your Summary Care Record will be available to authorised healthcare staff providing your care anywhere in England, but they will ask your permission before they look at it. This means that
if you have an accident or become ill, healthcare staff treating you will have immediate access to important information about your health.

Your GP practice is supporting Summary Care Records and as a patient you have a choice: 

• Yes I would like a Summary Care Record – you do not need to do anything and a Summary Care Record will be created for you. 

• No I do not want a Summary Care Record – Please ask at reception for an opt out form. Please complete the form and hand it to a member of the GP practice staff.

If you need more time to make your choice you should let your GP Practice know.

Additional copies of the opt out form can be collected from the GP practice, printed from the website www.nhscarerecords.nhs.uk  or requested from the dedicated NHS Summary Care Record Information Line on 0300 123 3020.

You can choose not to have a Summary Care Record and you can change your mind at any time by informing your GP practice. 

If you do nothing we will assume that you are happy with these changes and create a Summary Care Record for you. Children under 16 will automatically have a Summary Care Record created for them unless their parent or guardian chooses to opt them out.  If you are the parent or guardian of a child under 16 and feel that they are old enough to understand, then you should make this information available to them. 

Yours sincerely 

DRS PRASAD, HUTSON & CHANDRAN

                                                                                                                   

Your Electronic Patient Record & the Sharing of Information
- A Patient’s Guide

Please read this leaflet carefully. It will give you information about the sharing of your electronic patient record and the choices you need to make

Today, electronic records are kept in all the places where you receive healthcare. These NHS Care Services can usually only share information from your records by letter email, fax or phone. At times, this can slow down your treatment and mean information is hard to access.

Your GP practice uses a computer system called SystmOne that allows the sharing of full electronic records across different NHS Care Services. We are telling you about this as a patient at this practice as you have a choice to make about how your practice shares information about your care from your electronic patient record. This form is not about your Summary Care Record (SCR), it is asking your sharing preferences regarding your full electronic GP record. You can choose to share or not to share your electronic GP record with other NHS Care Services.

How is my decision recorded?

Your GPs computer system has two settings to allow you to control how your medical information is shared:

Sharing Out:
 This controls whether your full GP electronic patient record can be shared with other NHS Care Services where you are treated.  Please record your preference: 

Please tick:	Sharing Out		Yes (shared)	□  or 		No (not shared) □

Sharing In:
Declaration: By registering with this Practice you are agreeing to the sharing in of your medical history from other NHS Care Services

Patient Name (Print Name): ___________________________________________

Date of Birth:  ____/____/____

Patient Signature: _________________________________ Date: ____/____/____