New Patient Registration Form - Adult

New Patient Registration Form- Adult

Thank you for applying to join Uppingham Surgery. We would like to gather some information about you and ask that you fill in the following questionnaire. You don’t have to supply answers to all of the questions but what you do fill in will help us give you the best possible care. Please supply two forms of Identification with your completed form, a photographic form of ID (such as passport or driving license) and proof of your home address (such as a recent bank statement or document relating to your new home).

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Next of Kin/Emergency Contact Name*
Next of Kin/Emergency Contact relationship to you*
Next of Kin/Emergency Contact telephone number*
Next of Kin/Emergency Contact address (if different to yours)
Data Sharing
Summary Care Record
Summary Care Record (SCR) Your SCR is an electronic summary of key medical information taken from your GP medical record. If you need healthcare away from your usual doctor’s surgery, your enhanced SCR will provide those looking after you with key information to help them give you better and quicker care. Please refer to ‘What is a Summary Care Record’ document:
More information can be found by visiting: https://digital.nhs.uk/
- Tick this box if you wish to have an enhanced SCR with core and additional information (recommended)
- Tick this box if wish to opt-out the child of the SCR
Medical Interoperability Gateway (MIG)
The MIG enables secure sharing of relevant medical information from your GP record with other healthcare professionals who are providing you with direct care, even if they are not using the same electronic records system. At point of care you will be asked if you consent to the care service seeing essential elements of your record.
More information can be found by visiting: https://healthcaregateway.co.uk/?s=products
- Tick this box if you wish to opt-out of the MIG data sharing
Risk Stratification Preferences
Risk stratification is the process of identifying the relative risk of patients in a population by analysing their medical history. It's a key enabler for improving the quality of care delivered by the NHS.
Uppingham Surgery is taking part in the Risk Stratification programme and will be uploading patient identifiable data for analysis. Patient identifiable information will only be viewable at GP practice level. Any NHS organisation external to the practice using risk stratification will only see anonymised data.
For more information please visit our website at www.uppinghamsurgery.nhs.uk
- Tick this box if you wish to opt-out of the Risk Stratification programme
Enhanced Data Sharing Module (EDSM)
Uppingham Surgery use a clinical computer system called SystmOne to record your medical information.
With your consent, you can allow your full GP record to be shared with other healthcare services that are providing care for you and who also use SystmOne.
These other services will always ask consent to view your record. For more information please visit our website at www.uppinghamsurgery@nhs.uk
- Tick this box if you wish to opt-out of the Enhanced Data Sharing Module
*Do you consent to receive the following types of communication (if offered) from Uppingham Surgery?*
- Email
- Mobile phone text messages
- Answering machinemessages

Medical Details
In order to continue to receive your repeat medications you’ll need to make a new patient health check appointment and bring in your last repeat prescription. (Please note, certain medications will require an appointment with the GP before they can be prescribed)
Please allow plenty of time to organise repeats. Please provide us with your repeat medication list found on the right hand side or a printed prescription.
Are you allergic to any medicines?*
- Yes
- No
Please specify
Please list any other allergies/intolerances (i.e nuts, gluten, pollen, animal hair or certain foods). Mark 'none' if you have no other allergies that you know of
The Accessible Information Standard (AIS)
For further information please visit https://www.england.nhs.uk/ourwork/accessibleinfo

If there are any problems with your registration we’ll contact you to clarify any issues, but once your details have been entered into our computerized records…

On-line Services

You will be able to register with our on-line service and access appointments, prescriptions and some sections of your own medical record via the internet. All of the details that you need for this are available by requesting to be registered at reception.

New Patient Health-check

You will be eligible for a new patient health-check with a Practice Nurse/Health Care Assistant. Contact reception if you should like to take this up.

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New Patient Registration Form – Adult

New Patient Registration Form- Adult

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