GMS1 + New Patient Registration

Please complete the form below to register at Hyde Park Surgery.

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Non-urgent advice: About this form

This form will allow us to register you at our surgery. We will contact you once the registration is completed. Please complete the form fully and ensure you use your full name, date of birth, full address in Leeds (including Flat number and Block number if applicable). We prefer 2 forms of ID to be uploaded for each person but please contact the surgery if this is an issue.

Personal Details

First Name

Surname

Previous Surname Optional

Date of Birth

Day

Month

Year

NHS Number Optional

Home Address

House Number and Street City

Postcode

Post Code

Enter Email Optional Confirm Email Optional

Mobile Number

Landline Number Optional

Main Spoken Language

Is your gender the same as you were assigned at birth?

Yes

Which of the following best describes you?

Please state other

Which of the following best describes how you think of yourself?

Please state other

Have you served in the armed forces?

Yes

Are you a carer?

I am a full time carer

I am a part time carer

I am not a carer

Someone who is looking after a family member, partner, or friend who needs help because of illness, frailty, or disability

Ethnicity

What is your ethnicity?

Religion Optional

Verify Identity

You will need the following to register with the practice.

ID Optional

NHS number Optional

Please contact reception if you do not have these available.

Please upload a photo of your ID by holding it next to your face. Ensure the ID is visible and readable. Optional

Drop files here or

Max. file size: 1 GB.

Are you resident in the UK

Anybody in England can register with a GP practice and receive free medical care from that practice. However, if you are not ‘ordinarily resident’ in the UK you may have to pay for NHS treatment outside of the GP practice. Being ordinarily resident broadly means living lawfully in the UK on a properly settled basis for the time being. In most cases, nationals of countries outside the European Economic Area must also have the status of ‘indefinite leave to remain’ in the UK.

Are you normally resident in the UK

Yes

Some services, such as diagnostic tests of suspected infectious diseases and any treatment of those diseases are free of charge to all people, while some groups who are not ordinarily resident here are exempt from all treatment charges.

More information on ordinary residence, exemptions and paying for NHS services can be found in the Visitor and Migrant patient leaflet, available from your GP practice.

You may be asked to provide proof of entitlement in order to receive free NHS treatment outside of the GP practice, otherwise you may be charged for your treatment. Even if you have to pay for a service, you will always be provided with any immediately necessary or urgent treatment, regardless of advance payment.

The information you give on this form will be used to assist in identifying your chargeable status, and may be shared, including with NHS secondary care organisations (e.g. hospitals) and NHS Digital, for the purposes of validation, invoicing and cost recovery. You may be contacted on behalf of the NHS to confirm any details you have provided.

Please tick one of the following boxes:

I understand that I may need to pay for NHS treatment outside of the GP practice

I understand I have a valid exemption from paying for NHS treatment outside of the GP practice. This includes for example, an EHIC, or payment of the Immigration Health Charge (“the Surcharge”), when accompanied by a valid visa. I can provide documents to support this when requested

I do not know my chargeable status

NON-UK EUROPEAN HEALTH INSURANCE CARD (EHIC), PROVISIONAL REPLACEMENT CERTIFICATE (PRC) DETAILS and S1 FORMS

Complete this section if you live in another EEA country, or have moved to the UK to study or retire, or if you live in the UK but work in another EEA member state. Do not complete this section if you have an EHIC issued by the UK.

Do you need to complete this section?

Yes

Go to the next section

Details from your EHIC or PRC

Do you have a non-UK EHIC or PRC?

Yes

If you are visiting from another EEA country and do not hold a current EHIC (or Provisional Replacement Certificate (PRC))/S1, you may be billed for the cost of any treatment received outside of the GP practice, including at a hospital.

By continuing with this form you are agreeing to this

Card details

How will your EHIC/PRC/S1 data be used?

By using your EHIC or PRC for NHS treatment costs your EHIC or PRC data and GP appointment data will be shared with NHS secondary care (hospitals) and NHS Digital solely for the purposes of cost recovery. Your clinical data will not be shared in the cost recovery process.

Your EHIC, PRC or S1 information will be shared with The Department for Work and Pensions for the purpose of recovering your NHS costs from your home country.

Country code Optional

Name Optional

Given Names Optional

Date of Birth

Day Optional

Month Optional

Year Optional

Personal Identification Number Optional

Identification number of the institution Optional

Identification number of the card Optional

Expiry Date

Day Optional

Month Optional

Year Optional

PRC valid from:

Day Optional

Month Optional

Year Optional

PRC valid to:

Day Optional

Month Optional

Year Optional

Assesment

Please tell us about your health. The information will help us to make an initial assessment of your health which will help your future treatment

Personal Background

What is your place of birth?

What is your current occupation? Optional

Previous Doctor

Please tell us about your previous details

Are you:

Do you know your NHS number?

Yes

NHS number

10 digit number, can be found on prescription

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

Address

Street Address Address Line 2 City Post Code

Name of previous doctor while at that address

Address of previous doctor

If you are from abroad

Your first UK address where registered with a GP

Street Address Optional Address Line 2 Optional City Optional Post Code Optional

If previously resident in UK, date of leaving

Day Optional

Month Optional

Year Optional

Date you first came to live in the UK

DD dash MM dash YYYY

If you are returning from the Armed Forces

Address before enlisting

Street Address Optional Address Line 2 Optional City Optional Post Code Optional

Service or personnel number Optional

Enlistment date

Day Optional

Month Optional

Year Optional

Registering a child

Are you are registering a child under 5?

Yes

Contact Preferences

I consent for the GP Practice to contact me regarding matters directly related to my healthcare by:

SMS Text

Yes

Mobile number

Yes

Please enter the email address where we can contact you

Enter Email Confirm Email

Privacy preferences

Summary Care Record

The summary care record is a national database for the NHS and holds details of your name, date of birth, allergies and any medication you are taking. You record will be automatically uploaded onto this database.

SCR Consent

YES I would like a summary care record – you do not need to do anything and a summary care record will be created for you

NO I do not want a summary care record

Patient Choices regarding sharing of health records

Electronic records are kept in all the places where you receive healthcare. Often, NHS care services can usually only share information from those records by letter, email, fax or phone. At times, this can slow down your treatment and mean information is hard to access.

This service uses a secure computer system that allows the sharing of full electronic records across different NHS care services. This form is not about your Summary Care Record (SCR), it is asking your sharing preferences regarding your full detailed electronic record.

We are telling you about this, as you have a choice to make. You can choose to share or not to share your full electronic record with other NHS care services where you are treated and whether we can view records held by those other services.

If you choose to make your record shareable, your clinical details will only viewable by clinical teams who are treating you. Each clinical team which cares for you now or in the future will ask your permission to view your shared record. You can also ask for part of your record to be made private – not shareable. All record accesses are recorded and auditable.

If you choose not to make your records shareable, we will respect your wishes and will do our best to make your care safe and efficient. However, denying the clinical teams caring for you the ability to access important clinical details could compromise your care.

If you require further information please ask at reception. You can also visit the NHS Care records website at http://www.nhscarerecords.nhs.uk/carerecords or download the NHS Care Record Guarantee from http://www.nigb.nhs.uk/pubs/nhscrg.pdf

Q. How is my decision recorded? A. You have two choices:

Sharing Out – This controls whether your full electronic patient record can be shared with other NHS care services where you are treated. Please record your preference:

Yes (shareable)

No (not shareable)

Sharing in – This controls whether you agree for this practice to view information you've agreed to share at other NHS care services. Please record your preference:

Yes (viewable)

No (not viewable)

You and Your Family History

Have you or any of your immediate family members (father, mother, brother or sister) suffered from the following conditions before the age of 65?

Cancer

Yes

You and/or a Family Member?

Family Member

Which Family Member?

Stroke or mini stroke (also known as TIA)

Yes

You and/or a Family Member?

Family Member

Which Family Member?

Heart disease

Yes

You and/or a Family Member?

Family Member

Which Family Member?

High Blood Pressure

Yes

You and/or a Family Member?

Family Member

Which Family Member?

Diabetes

Yes

You and/or a Family Member?

Family Member

Which Family Member?

Asthma

Yes

You and/or a Family Member?

Family Member

Which Family Member?

Have you ever had a surgical operation?

Yes

Please give us some details about your operation including dates

Women's health

This section is about women's health. Are you female?

Yes

Move onto the next section

Women's health screening

Have you ever had a cervical smear test?

Yes

When was your last cervical smear?

Have you ever had a mammogram?

Yes

When was your last mammogram?

Have you ever had a hysterectomy?

Yes

When was your hysterectomy?

Medication

What medication are you currently taking (whether prescribed by a GP, from hospital, over-the-counter or from a pharmacy)? Optional

Allergies

Do you have any known allergies?

Yes

Please list your allergies

Smoking Status

Do you smoke?

How many cigarettes do you smoke per day?

Would you like help stopping smoking?

Yes

Quitting smoking is the best thing you’ll ever do, find out why now is the right time to quit.

There are a number of ways to quit smoking, but one of the more successful ways is by using NHS support. You are four times more likely to quit by using NHS stop smoking services than going it alone (cold turkey) and it’s completely free of charge.

phone 0800 169 4219.

text SMOKEFREE to 60066.

email: stopsmokingleeds@nhs.net

Contact the team at the surgery with any questions you may have.

Alcohol – Audit C

How often do you have a drink containing alcohol?

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

One unit of alcohol (10ml) is the equivalent to: A single measure of spirits (ABV 37.5%); half a pint of average-strength (4%) lager; two-thirds of a 125ml glass of average-strength (12%) wine; half a 175ml glass of average-strength (12%) wine; a third of a 250ml glass of average-strength (12%) wine.

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?

Score

Your alcohol intake is likely to be causing you harm. Please continue to answer the questions below

Your alcohol intake is unlikely to cause any significant harm

Audit C – continued

How often during the last year have you found that you were not able to stop drinking once you had started?

How often during the last year have you failed to do what was normally expected from you because of your drinking?

How often during the last year have you needed an alcoholic drink in the morning to get yourself going after a heavy drinking session?

How often during the last year have you had a feeling of guilt or remorse after drinking?

How often during the last year have you been unable to remember what happened the night before because you had been drinking?

Have you or somebody else been injured as a result of your drinking?

Has a relative or friend, doctor or other health worker been concerned about your drinking or suggested that you cut down?

Hidden

Score 2 Optional

Total Score

Thank you for completing this section. One of the doctors will review your score and advise you about what to do next once the form has been completed. Please contact our reception team by phone if you are worried in the meantime.

COMMUNICATION/INFORMATION NEEDS – HELP US TO HELP YOU

Do you have any communication/information needs?

Yes

Do you have any sensory impairment, physical or mental disabilities? Please tell us so that we can try to accommodate them. For instance if you are profoundly deaf, an interpreter can be arranged.

Deafness

Yes

Speech impairment

Yes

Registered blind/partially sighted

Yes

Other.. Optional

NHS Organ Donor registration

This service changed in 2020 and patients will automatically be registered to join the NHS Organ Donor Register as someone whose organs may be used for transplantation after death. If you wish to opt out then visit www.organdonation.nhs.uk

NHS Blood Donor registration

I would like to join the NHS Blood Donor Register as someone who may be contacted and would be prepared to donate blood

Yes Optional

No Optional

ADULTS ONLY

Have you given blood in the last 3 years?

Yes Optional

No Optional

For more information, please ask at reception for an information leaflet or visit the website UK Blood and Transplant, or call 0300 123 23 23.

Patient Declaration

A parent/guardian should complete the form on behalf of a child under 16. Are you signing on behalf of a child?

Yes

Relationship to child

Your Name

Date of Birth

Day Optional

Month Optional

Year Optional

Declaration

I declare that the information I give on this form is correct and complete. I understand that if it is not correct, appropriate action may be taken against me. Optional

Comments Optional

This field is for validation purposes and should be left unchanged.