Care Home Registration Form

Complete this form for a patient living in a care home to join our surgery and our Care Home Assessment Team.

You must complete one form per person.

Last Updated: 13/05/2024

Patient's Details

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

Please Note: These questions are optional and your answers will not affect your entitlement to register or receive services from the NHS but may improve access to some NHS priority and service charities services.

Your previous address in the UK (including postcode)?

Name of previous GP practice while at that address

Address of previous GP practice while at that address

IF YOU ARE FROM ABROAD

Date you first came to live in the UK?

Your first UK address where registered with a GP

If previously resident in the UK, date of leaving

Armed Forces

Please indicate if you have served in the UK Armed Forces and/or been registered with a Ministry of Defence GP in the UK or overseas:

Regular

Reservist

Veteran

Family Member (Spouse, Civil Partner, Service Child

Address before enlisting (including postcode)?

Service or Personnel Number

Enlistment Date

Discharge Date (if applicable)?

Nominate a Pharmacy

Our prescriptions are now signed, sent and processed electronically. Prescriptions are sent electronically to your nominated pharmacy.

You will need to nominate a pharmacy.

Use the NHS 'Find a Pharmacy' tool to choose your preferred pharmacy:

Find a pharmacy - NHS (www.nhs.uk)

Please give the name, address and postcode of the Pharmacy you would like to collect your prescriptions from. *

HEALTH QUESTIONS

It can take time for your medical records to get to us from your previous surgery. This is why we ask you to complete our health questionnaire below. It helps us to have as much medical information about you, as possible. Particularly when treating you as a new patient.

Lifestyle Questions

For guidance on calculating alcohol units use this tool:

Interactive Alcohol Unit Calculator

Family history

When completing this section, a 'Close Relative' means:

Mother
Father
Brother
Sister

Have any close relatives ever suffered from any of the following? Tick as many boxes as applies.

Heart attack

Stroke

Diabetes

High blood pressure

Asthma

Glaucoma

Cancer

If you have ticked any of the above, please tell us which close family member suffered from which disease?

Immunisations

We don't always receive your immunisation history from your previous surgery. If you know your immunisation history please tell us. We can then keep your medical record as accurate as possible.

Often you can access this information via the NHS App or NHS Website Login or other online health apps such as SystmOnline, Airmid, Patient Access etc.

If you know your immunisation history, please tell us by providing the name of the immunisation and the year you had it.

Have you had Mumps? *

Yes

Don't know

NHS Organ Donor

All adults in England are now considered to have agreed to be an organ donor when they die unless they have recorded a decision not to donate or are in one of the excluded groups.

If you would like to opt-out or to learn more please visit:

https://www.organdonation.nhs.uk/register-your-decision/

IF YOU ARE COMPLETING THIS FORM FOR SOMEONE ELSE

What is your relationship to the person being registered?

Parent

Guardian

Carer

Other

If you selected 'Carer' what type of carer are you?

Young carer

Paid as a job

Unpaid but may not get benefits

Foster carer

None of the above

If you selected 'Other' please give us more detail

What are your details? (name, relationship, contact number)

Our Privacy Notice, Data Sharing Policy and Options

Before completing this section, please read our Privacy Notice and Data Sharing Policy. These give you more information on:

The data we hold on you
What we do with your data
Who we share your data with
Your rights under General Data Protection Regulation (GDPR)

You can view the Privacy Notice and Data Sharing Policy on our website:

https://www.coastalmedicalpartnership.nhs.uk/see-our-privacy-notice-and-data-sharing-policy

I am happy for my clinical records to be shared via your 'SystmOne' computer system with other services directly involved in my care, such as Local Hospitals, Community Doctors and Nurses or Social Care Services *

Yes No

I am happy to have a Summary Care Record (SCR) containing information about my medication and allergies, name, address, date of birth and NHS number. I understand it can be seen and used by authorised staff in other areas of the health and care system involved in my care. *

Yes No

I am happy to have a Hampshire Healthcare Record (CHIE). The Care and Health Information Exchange (CHIE) stores summary information in one place so that health professionals can view it to deliver better care to you. This record contains more information than the SCR but is only visible in Hampshire. *

Yes No

I am happy for my data to be extracted by NHS Digital. NHS Digital extracts data from all GP It systems in order to support vital health and care planning and research. This data is 'pseudonymised', which means it cannot be attributed to a specific patient without the use of additional information which is kept separate. *

Yes No

CONFIRMATION

By submitting your data online via our encrypted process, you are giving us permission to register you as a patient. We only use your information to set you up as a new patient. Once your application is complete, a PDF version will be added to your notes and the form deleted from our online contact form system.

I hereby certify that the above statements are true and correct to the best of my knowledge. *

Yes No

Signed *

Date *

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Care Home Registration Form

Further Information