Temporary Registration With Our Care Home Assessment Team

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

You must complete one form per person.

Last Updated: 14/05/2024

Patient's Details

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. *

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/

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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Temporary Registration With Our Care Home Assessment Team

Further Information