New patient registration form – Channel View Medical Group

Please complete the form below to register with the practice. We will contact you if we need any further information.

Step 1 of 9

11%

Which branch would you like to be registered at?(Required)

The Den

Channel View

Bishopsteignton

Chudleigh

Your contact details

NHS Number

Name(Required)

First Names Surname

Previous surname (if applicable)

Date of Birth(Required)

Day

Month

Year

Male/Female(Required)

Male

Female

Current home address(Required)

Previous address(Required)

Current postcode(Required)

Previous postcode(Required)

Home Telephone(Required)

Mobile Telephone

I consent to be contacted by SMS on this number*

Work Telephone

Email(Required)

Enter Email Confirm Email

I consent to be contacted by email at this address*

* It is your responsibility to keep us updated with any changes to your telephone number, email & postal address. We may contact you with appointment details, test results, health campaigns or Patient Participation Group details If you do not consent to being contacted by SMS or Email, please tick here:

SMS text

Next of kin name(Required)

First Last

Relationship to you:(Required)

Contact number:(Required)

Family registered with us

Has the patient been registered in the NHS before?(Required)

Yes

If no please state date entered UK:

Other details

Previous GP name and address

Country of birth(Required)

Ethnicity(Required)

White (UK)

White (Irish)

White (Other)

Black Carribbean

Black African

Black Other

Bangladeshi

Indian

Pakistani

Chinese

Other

Religion(Required)

C of E

Catholic

Other Christian

Buddhist

Hindu

Muslim

Sikh

Jewish

Jehovah's Witness

No religion

Other

Housing(Required)

Own house

Rented house

Shared house

Nursing home

Residential home

Sheltered home

Homeless

Housebound

Asylum Seeker

Refugee

Other

Employment(Required)

Employed

Self employed

Student

Unemployed

House husband

House wife

Carer

Retired

Other

Are you an overseas visitor?(Required)

Yes

Do you hold a European Health Insurance Card?

Please bring details with you to the surgery if you have a EHIC

Yes

Communication needs

What is your first language?(Required)

Do you need an interpreter?

Yes

Language of interpreter

Do you have any specific communication needs? By leaving this section blank we will not record the need for alternative communication methods in your record.

Hearing aid

Lip reading

British sign language

Large print

Makaton sign language

Braille

Guide dog

Do you have a learning disability?

If yes, please request a Learning Disability Tool form

Yes

Carers

A Carer is someone, who, without payment, provides help and support to a partner, child, relative, friend or neighbour, who could not manage without their help. This could be due to being elderly, physical or mental illness, addiction or disability. We would be grateful if you could complete the following questions for the Practice Carer’s Register. The register enables the practice to proactively manage carer’s needs with the practice and to consider the provision of services to carers. The practice will also ensure that all patients who are carers are informed of and supported in joining the local carer’s link.

Are you a carer?(Required)

Yes - Informal/Unpaid carer

Yes - Occupational/Paid Carer

Name of the person you care for:

First Last

What is your relationship with the person you care for?

DOB of the person you care for:

DD slash MM slash YYYY

Address of the person you care for:

Telephone number of the person you care for:

NHS number of the person you care for:

Please contact the following number for advice on a free carers Health and Wellbeing check 03456 434 435

Are you being cared for?(Required)

Yes

Name of your carer:

First Last

What is your relationship with your carer?

DOB of your carer:

MM slash DD slash YYYY

Address of your carer:

Telephone number of your carer:

NHS number of your carer:

If you consent to your Carer being informed of any medical information about you which is held at the practice, please check the box below; if NOT leave blank

I am happy for my carer to be informed of any medical information about me which is held by the practice.

Your medical information

Have you suffered from any of the following conditions?

Asthma

COPD

Epilepsy

Heart disease

Heart failure

Hypertension (High blood pressure)

Diabetes

Kidney disease

Stroke or Transient Ischaemic attacks

Depression or mental health problems

Underactive thyroid

Cancer

Please state the type of cancer

Any other conditions, operations or hospital admission details:

If you are currently under the care of a Hospital or Consultant outside our area, please tell us here:

Family history

Please record any significant family history of close relatives with medical problems and confirm which relative e.g. mother, father, brother, sister, grandparent

Asthma

COPD

Epilepsy

Heart disease

Stroke

Blood pressure

Diabetes

Kidney disease

Liver disease

Depression

Thyroid

Cancer

Other

Please give any details if you have ticked any of the above

ALLERGIES: Please list any allergies or sensitivities you have including drug allergies below

Current medication

Please check and include as much information about your current medication below Please give us your previous repeat medication list if possible and a medication review appointment may be needed

Your lifestyle

Alcohol consumption - How many units of alcohol do you consume in a week?

Approximately - 1 drink = 1/2 pint of beer or 1 glass of wine or 1 single spirits. 1 unit of alcohol = 10cc of alcohol. So, a small glass (125cc) of 12% wine is 12.5 * 0.12 = 1.5 units. Find out more about alcohol units on the NHS website

How often do you have a drink containing alcohol?(Required)

Never

Monthly or less

2 to 4 times / month

2 to 3 times / week

4+ times / week

How many units of alcohol do you drink on a typical day when you are drinking?(Required)

1 - 2

3 - 4

5 - 6

7 - 9

10+

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?(Required)

Never

Less than monthly

Monthly

Weekly

Daily or almost daily

Part one score

A score of less than 5 indicates lower risk drinking

Alcohol consumption – Part Two

Scores of 5 or more in Part 1 requires the following 7 questions to be completed

How often during the last year have you found that you were not able to stop drinking once you had started?
Never
Less than monthly
Monthly
Weekly
Daily or almost daily

How often during the last year have you failed to do what was normally expected from you because of your drinking?
Never
Less than monthly
Monthly
Weekly
Daily or almost daily

How often during the last year have you needed an alcoholic drink in the morning to get yourself going after a heavy drinking session?
Never
Less than monthly
Monthly
Weekly
Daily or almost daily

How often during the last year have you had a feeling of guilt or remorse after drinking?
Never
Less than monthly
Monthly
Weekly
Daily or almost daily

How often during the last year have you been unable to remember what happened the night before because you had been drinking?
Never
Less than monthly
Monthly
Weekly
Daily or almost daily

Have you or somebody else been injured as a result of your drinking?
No
Yes, but not in the last year
Yes, during the last year

Has a relative or friend, doctor or other health worker been concerned about your drinking or suggested that you cut down?
No
Yes, but not in the last year
Yes, during the last year

Score - part 2
0 – 7 Lower risk, 8 – 15 Increasing risk, 16 – 19 Higher risk, 20+ Possible dependence.

Total Score for alcohol questionnaire(Required)

Smoking

What is your smoking status?(Required)
Never smoked
Ex-smoker
Smoker

Do you use an e-Cigarette?(Required)
No
Ex-user
Yes

How many cigarettes did/do you smoke per day?

Would you like advice/help on quitting?
Yes
No
For further information please see: www.nhs.uk/smokefree

Height and weight

Your height:(Required)

Your weight:(Required)

Waist circumference

Women only

Do you use any contraception?
Yes
No
If needed, please book an appointment

Do you have a coil or implant in situ?
Yes
No

Date coil or implant was inserted

Are you currently pregnant or think you may be?
Yes
No

Please give your expected due date

Students only

Students are at risk of certain infections including mumps, meningitis and sexually transmitted infections, as well as mental health issues including stress, anxiety and depression. Please see www.nhs.uk/Livewell/Studenthealth

I am less than 24 years old and have had two doses of the MMR Vaccination
Yes
No
Unsure

I am less than 25 years old and have had a Meningitis C Vaccination
Yes
No
Unsure

Electronic prescribing

If you would like your prescriptions to be sent electronically, please provide details of the pharmacy you would like to use:
Lloyds Pharmacy
Well Pharmacy, Regent Street
Well Pharmacy, Coombe Park Road
Boots, Teignmouth
Ross Chemist, Bishopsteignton
Other

Patient participation group

We are committed to improving the services we provide. The Patient Participation Group is a mechanism for us to gain valuable feedback from our patients about their experiences, views and ideas for improving our services.

Would you like to be involved in our Patient Participation Group?
Yes
No

NHS organ and blood donation

Organ donation in England has changed to an opt out system. You still have a choice whether or not you want to become an organ donor. We will always ask your family to support your decision. So whatever you choose, it's really important that you let them know. More about the donation laws in England

Your choice to opt in or out
I am already registered as a donor
I wish to be a donor - all body parts
I wish to be a donor - for certain body parts
I do not wish to be a donor

Please provide details

NHS Blood Donor registration
I am already a donor
I wish to be a donor
I do not wish to be a donor

To register: Online: www.blood.co.uk/the-donation-process/recognising-donors Telephone: 0300 123 23 23 to speak to an advisor who will send out a donor card.

NHS patient information sharing - my choices

This section of the form covers the Summary Care Record and the Enhanced Data Sharing Model 'SystmOne'. If you would like to know more about these things, please see the following links. NHS Health Records - Enhanced Data Sharing Model

Please complete and/or tick the boxes below to detail your personal decisions regarding the 2 aspects of NHS patient data sharing. It is very important you sign this form to say that you understand and accept the risks to your personal health care if you do decide to opt out of SCR or EDSM. You will need to do this when you next visit the surgery.

1. SCR - NHS SUMMARY CARE RECORD(Required)
Express consent for medication, allergies and adverse reactions only
Express consent for medication, allergies, adverse reactions and additional information
Express dissent – Patient does not want a summary care record and fully understands the risks involved with this decision

EDSM – ENHANCED DATA SHARING MODEL "SystmOne" Sharing Out – Do you consent to the sharing of data recorded by your GP practice with other NHS organisations that may care for you?(Required)
YES share data with other NHS organisations
NO do NOT share any data recorded by my GP Practice; I fully accept the risks associated with this decision

Sharing In – Do you consent to your GP Practice viewing data that is recorded at other NHS organisations and care services that may care for you?(Required)
Consent Given
Consent Refused; I fully accept the risks associated with this decision.

Request to access SystmOnline (OPTIONAL)

I would like to request a password and login to enable me to access SystmOnline to book appointments, request repeat prescriptions, view my coded medical record and my summary care record. I understand the importance of keeping my login and password details safe for security purposes. I also understand that I may be contacted by the practice to assess this service and I am happy to provide the above information to Channel View Medical Practice and Practice Patient Group for the purpose of receiving information and newsletters.

Please note that we only offer SystmOnline access for patients aged 16 and over. If you are registering for your own online services you will need to complete this form and return it with photographic ID. If you are registering for a “proxy” user you will need to supply photographic ID and have the box below completed by the patient granting you access. Please note we only proxy grant access to repeat medications and appointments as standard.

I wish to have access to the following online services (please tick all that apply):
Booking telephone appointments with a GP
Requesting repeat medications
View my medical record (subject to policy)
Access to my Summary Care Record
Complete online questionnaires

I wish to have my username and password sent to me via:
Email (please ensure you have provided your email address)
Text (please ensure you have provided a mobile number)
Verbally

Signature

You will be asked to sign this form when you visit the practice and provide ID and proof of address

Are you signing this form on behalf of a patient?(Required)
Yes
No

Your full name
Please enter your name here to confirm you have completed the form

Today's date(Required)
DD slash MM slash YYYY

Consent(Required)
Please note that no medical information or questions will be responded to. The data you supply on this form will be stored on our website, which is hosted by a third party, until it has been processed by the practice. The data will be used lawfully, in accordance with the Data Protection Act 2018, which gives you the right to know what information is held about you, and sets out rules to make sure that this information is handled properly. The practice privacy policy can be viewed on this website.
I agree to the privacy policy.