GPS Healthcare - Under 16's New Patient Registration Form Jan 24

Patient's Details

Family Details

Next of kin

Other Information

What is your ethnic group?

Please tick one box that best describes your ethnic group or background from the options below:

Health Check Information

Family History

Please help us trace your previous medical records by providing the following information

Vaccinations

Details of routine childhood vaccinations (You may wish to supply a copy of their red book personal child health record)

Current Medication

Please give details of any medication which you take (prescribed or otherwise):

SystmOne Enhanced Data Sharing

The following service is an “Opt-In” Service. You do need to complete the section below so that we can record your wishes. If you don’t complete and return this form you will be asked when you attend the surgery, so please do read and consider your choices. SystmOne Enhanced Data Sharing SystmOne is a clinical computer system produced by a company called TPP. It lets NHS staff record patient information securely onto a computer. This information can then be shared with other clinicians, if needed and agreed by you, so that everyone caring for you is fully informed about your medical history, including medication and allergies. In Solihull, many GP practices, HEFT Community services, The Walk in Centre and Marie Curie all use SystmOne so that patients can really benefit from joined up care. With your permission we can make your medical record shareable (Sharing Out). You will then be asked, when you attend other services, whether you are happy for them to access your record for information to improve your care and you can make a decision for each individual service i.e. you may want the district nurses to be able to access your record but if you are attending the smoking cessation service, you may not feel that they need to see your record. You will also need to tell each service if you are happy for them to let your GP see details of the treatment you receive from that service (Sharing In). Further information can be obtained from reception if needed. Sharing Out – I would like to make my record shareable so that other services can access it when I give them my permission to

DATA SHARING INFORMATION HOW WE CAN USE YOUR DATA TO IMPROVE YOUR CARE – YOUR CHOICES You need to let us know if you wish to give consent.

Summary Care Record Your Summary Care Record will hold the following information: Allergies and adverse reactions Acute medication Repeat medication Discontinued medication in the last 6 months Your Summary Care Record could be accessed, with your permission, by participating hospitals throughout the UK if you needed care. A Summary Care Record will automatically be created on completion of your registration unless you advise us to the contrary in writing. If you do not wish to have a Summary Care Record created, please contact the surgery within 2 weeks of your registration. Your Care Connected This is a more detailed record that can be shared with local hospitals and community services throughout Solihull, Birmingham and Sandwell. This enables all organisations to share important details of your medical history along with investigations, test results, medication etc. The aim is to improve communication across local GP’s, hospitals and community services, avoid duplicating investigations such as blood tests and also prevent patients from having to repeat their “story” at every service. “Your Care Connected” Record will automatically be created unless patients advise the practice that they wish to opt out If at any time you wish to OPT OUT of the Summary Care Record please contact the surgery on 0121 796 2777. If at any time you wish to OPT OUT of Your Care Connected please contact the surgery on 0121 796 2777 

Complete Registration

*Not all doctors are authorised to dispense medicines