Adult Registration Questionnaire

Please note: 
All new registrations require the completion of the GMS1 Form. Registrations cannot be processed without this.

Adult Registration Questionnaire

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

If you are from abroad
If you are returning from the Armed Forces
Additional Details about you

For women only

Next Of Kin / Emergency contact
Carers Information

A carer is a friend / family member who gives their time to support a person in their home, to an extent that the person could not remain at home if this care was not being provided. A carer can receive Carers Allowance (but not a wage) and the care they are giving will significantly affect their own life.

Your Health

(Please note you will be required to see the doctor for a first repeat prescription to be issued)

Have you ever had any of the following conditions? If yes, please provide the year of diagnosis.

Do you have Family History of any of the following?

If yes, please advise the family member/s who have the condition

Please tell us about your smoking habits

Exercise

Please tell us about your alcohol consumption

1 unit = normal half pint beer (284 ml) 4% or Single shot spirit (25ml) 40%.

1.5 units = small glass of wine (125 ml) 12.5% or Alcopop (275 ml) 5.5%

2 units = strong half pint beer (284 ml) 6.5% or medium glass of wine (175ml) 12.5% or normal large bottle/can beer (440ml) 4.5%

3 units = strong bottle/can beer (440ml) 6.5% or bottle of wine (750ml) 12.5% or bottle spirits (750ml) 40% or large glass of wine (250ml) 12.5%

If you are a student - Meningitis ACWY Immunisation

NHS England strongly recommends anyone who is starting university aged between 18-24yrs have an ACWY booster if you haven’t already done so.

Communication Preferences
Data Sharing

Summary Care Record (SCR)

As you are registering with this practice, we would like to recommend that you take advantage of the Summary Care Record (SCR). The Core SCR includes important information about your health: Medicines you are taking, allergies you suffer from and any bad reactions to medicines.

You can also choose to have additional information included in your SCR, which can improve the care you receive. This information includes: Your illnesses and health problems, operations and vaccinations you have had in the past, how you would like to be treated – such as where you would prefer to receive care; what support you might need and who should be contacted for more information about you.

You may need to be treated by health and care professionals outside of the practice who do not know your medical history. Having the additional information SCR can help the staff involved in your care access information more quickly, allowing them to make informed decisions about your healthcare. More information can be found by visiting www.nhscarerecords.nhs.uk

Medical Interoperability Gateway (MIG)

Whilst the SCR mentioned above shares a very small portion of your child’s medical record across the whole NHS, the MIG shares a much broader view of their records but only with local NHS providers – and only when you give explicit consent at the point of care.

For more information please visit https://healthcaregateway.co.uk/

The Accessible Information Standard (AIS)

Donor Registration Choices

For more information, please visit the website www.uktransplant.org.uk or call 0300 123 23 23

Online Patient Access

Once your application to join our practice has been accepted you’ll be able to order your repeat medications and book appointments. This service is known as Systmonline. To register visit www.springfieldsmedicalcentre.co.uk or ask reception for an application form. You need to bring the completed form to reception then you’ll be given a username and password so you can create the online account.

Electronic Prescription Service (EPS)

You will be able to nominate a pharmacy to collect your child’s prescriptions from. EPS enables prescribers, such as GP’s and practice nurses, to send prescriptions electronically to a pharmacy of the patient’s choice. This makes the prescribing and dispensing process more efficient and convenient for patients and staff. If you have already nominated a pharmacy, please tell us which pharmacy you have chosen. For further information about this service please talk to your pharmacist of choice.

Additional Information

Privacy Protection

Information submitted through secure forms is used only for the purposes of processing your request. We may be in touch with you in relation to the information submitted.

All Information submitted through secure forms is secured with a private key and is accessed over a secure connection by nominated staff. We have a strict confidentiality policy.

This information is not shared with any third party organisations.

This information is retained for up to 28 days.

Learn more about our Privacy Policy and Terms of Use. Should you have any concerns about sending your personal details using the web, please use one of the alternative methods offered by our organisation.


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