ADULT - New Patient Registration Form - Additional Questions

ANY SECTION UNFILLED WILL RESULT IN LATE REGISTRATION OR REGISTRATION MAY BE REJECTED. IF YOU ARE UNABLE TO FILL ONLINE FORM OR SUBMIT MANDATORY INFORMATION THEN YOU HAVE TO ATTEND THE SURGERY IN PERSON FOR REGISTRATION.

Last Updated: 10/12/2024

Consent to contact

Supplying us with your contact information gives consent for us to contact you where medically necessary.


Do you identify with a different gender to your birth gender?



Family history


Additional emergency contact details

Someone we can contact if medically necessary.







Prescribing declaration

Please book a face to face appointment with your new doctor before you ask for any prescriptions or medications.

 

If you are going to run out of medication,
ask your previous GP surgery for a prescription.

 

Please note we prescribe according to national guidelines.

 

Painkillers including Gabapentin and Pregabalin

We do not prescribe opiates or gabapentinoids for long term pain. This includes codeine, tramadol, zapain, dihydrocodeine, gabapentin and pregabalin. If you are taking these drugs for long term pain, we will prescribe a reducing course of these drugs and stop them. 

 

Sleeping tablets.

We do not prescribe long term benzodiazepines for sleep problems.
This includes zopiclone, zolpidem and temazepam. 
If you are
taking these drugs, we will prescribe a reducing course of these drugs and stop them.

 

Benzodiazepines

We do not prescribe long term benzodiazepines.  This includes diazepam.  If you are taking these drugs, we will prescribe a reducing course of these drugs and stop them.





Detailed Alcohol Consumption Questionnaire

A total of 5+ indicates increasing or higher risk drinking. An overall total score of 5 or above is AUDIT-C positive.

 

If your score is higher than 8 and would like Free NHS Help for alcohol problems please call the Surgery on 01273 685588 or contact: www.changegrowlive.org.uk who offer a drop-in service at:

Richmond House,

Richmond Road,

Brighton BN2 3FT

Tel: 01273 731 900

Mon-Tues-wed-Fri 9am-5pm/Thursday 9am-7pm & Saturday 10am-1pm.











Online Services Records Access

If you are interested in having access to the online records service, please read the leaflet below and notify reception when you register.

We will provide an additional form to be completed for this.

If you wish to, you can now use the internet to book appointments with a GP, request repeat prescriptions for any medications you take regularly and look at your medical record online. You can also still use the telephone or call in to the surgery for any of these services as well. It’s your choice.

 

Being able to see your record online might help you to manage your medical conditions. It also means that you can even access it from anywhere in the world should you require medical treatment on holiday. If you decide not to join or wish to withdraw, this is your choice and practice staff will continue to treat you in the same way as before. This decision will not affect the quality of your care.

 

You will be given login details, so you will need to think of a password which is unique to you. This will ensure that only you are able to access your record – unless you choose to share your details with a family member or carer.

 

It will be your responsibility to keep your login details and password safe and secure.  If you know or suspect that your record has been accessed by someone that you have not agreed should see it, then you should change your password immediately.

 

If you can’t do this for some reason, we recommend that you contact the practice so that they can remove online access until you are able to reset your password.

 

If you print out any information from your record, it is also your responsibility to keep this secure.  If you are at all worried about keeping printed copies safe, we recommend that you do not make copies at all.

 

The information that you can see online may be misleading if you rely on it alone to complete insurance, employment or legal reports or forms.

 

Be careful that nobody can see your records on screen when you are using Patient Online and be especially careful if you use a public computer to shut down the browser and switch off the computer after you have  finished.

 

The practice has the right to remove online access to services. This is rarely necessary but may be the best option if you do not use them responsibly or if there is evidence that access may be harmful to you.  This may occur if someone else is forcing you to give them access to your record or if the record may contain something that may be upsetting or harmful to you.  The practice will explain the reason for withdrawing access to you and will re-instate access as quickly as possible.

 

Before you apply for online access to your record, there are some other things to consider.

Although the chances of any of these things happening are very small, you will be asked that you have read and understood the following before you are given login details.

Things to consider

Forgotten history

There may be something you have forgotten about in your record that you might find upsetting.

Abnormal results or bad news

If your GP has given you access to test results or letters, you may see something that you find upsetting. This may occur before you have spoken to your doctor or while the surgery is closed and you cannot contact them. If this happens please contact your surgery as soon as possible. The practice may set your record so that certain details are not displayed online. For example, they may do this with test results that you might find worrying until they have had an opportunity to discuss the information with you.

Choosing to share your information with someone

It’s up to you whether or not you share your information with others – perhaps family members or carers. It’s your choice, but also your responsibility to keep the information safe and secure. If it would be helpful to you, you can ask the practice to provide another set of login details to your Online services for     another person to act on your behalf. They would be able to book appointments or order repeat prescriptions. They may be able to see your record to help with your healthcare if you wish. Tell your practice what access you would like them to have.

Coercion

If you think you may be pressured into revealing details from your patient record to someone else against your will, it is best that you do not register for access at this time.

Misunderstood information

Your medical record is designed to be used by clinical professionals to ensure that you receive the best possible care. Some of the information within your medical record may be highly technical, written by specialists and not easily understood. If you require further clarification, please contact the surgery for a clearer explanation.

Information about someone else

If you spot something in the record that is not about you or notice any other  errors, please log out of the system immediately and contact the practice as soon as possible.

 

More information

For more information about keeping your healthcare records safe and secure, you will find a helpful leaflet produced by the NHS in conjunction with the British Computer Society:

Keeping your online health and social care records safe and secure http://www.nhs.uk/NHSEngland/thenhs/records/healthrecords/Documents/PatientGuidanceBooklet.pdf  

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