Jubilee Park Patient Questionnaire

Patient Registration 2020

Last Updated: 26/06/2020

Patient Details













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




If you are from abroad




Were you ever registered with an Armed Forces GP






Complete Registration






NHS Organ Donor Registration

I want to register my details on the NHS Organ Donor Register as someone whose organs/tissue may be used for transplantation after my death. For more information, please ask for the leaflet on joining the NHS Organ Donor Register




NHS Blood Donor Registration

For more information, please ask for the leaflet on joining the NHS Blood Donor Register






SUPPLEMENTARY QUESTIONS | PATIENT DECLARATION for all patients who are not ordinarily 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. 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. 1. Please tick one of the following boxes:







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. 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 the GP practice, including at hospital).














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.

Your Contact Details




Jubilee Park Medical preferred Branch Location


Information About You






SMS Consent

As part of Health promotion and excellent service we may send you text information from time to time, or reminders of any appointments you have made at the surgery.


Carers


Medical Information




Advanced directive (Living Will)


Smoking




Family History


Other Health Questions




Local Pharmacy

Please nominate a pharmacy to have your prescriptions sent over electronically?



Consent Form

I, * INSERT NAME * have today been given the opportunity to discuss sharing of my patient record and have read and understood the leaflet “Your electronic patient record & the sharing of information” I understand that the same record is used to store information recorded by different members of the care teams who are currently involved in providing my care, including but not limited to doctors surgeries, district nurses, health visitors, physiotherapists, podiatrists, social care and child health. I understand that I will be asked to give consent by each care team before they are able to access or add to any shared data about me.


Consent Form Continued







Alcohol Consumption Questionnaire

Please answer the following questions and add up your score




Alcohol part 2

If you scored more than 5 in the above section, please answer the next set of questions








Next of Kin





Proof of Identity and Address Provided

Please bring a copy of proof of address and photo ID into the surgery



Signature