West Hampstead Medical Centre

Online New Adult Patient Registration

Dear Patient,

Please kindly take a few minutes to fully complete this form as best you can.

To fully complete the registration process please email to us one proof of photo identification (i.e. passport/UK driving license/national idenfication card/travel document) and one proof of address (i.e. utility bill/telephone bill/credit card bill/tenancy agreement/council tax bill) dated within the last 4 months. Please email the images of your documents (i.e. scanned copies/pictures) in a standard format (i.e. pdf/jpeg) to register.whmc@nhs.net.

If you cannot email to us the above documents please do come in person and we will photocopy your documents and attach them to your file.

PLEASE ALLOW 3-4 WORKING DAYS TO PROCESS YOUR ONLINE REGISTRATION THEN BOOK AN APPOINTMENT IF YOU REQUIRE MEDICATION. IF YOU REQUIRE MEDICATION SOONER PLEASE SPEAK TO RECEPTION.

N.B Please be aware that if you are on highly addictive or controlled medications (i.e. tramadol, diazepam, temazepam etc) that we are unable to prescribe these medications until we have your old medical records, so please liaise with the reception to ensure we have these before booking an appointment. Please also note that we do not prescibe out of accordance with national and local medicines management guidelines.

For Details about the Summary Care Record, CIDR and Care.data please go to the following links:https://digital.nhs.uk/summary-care-records, https://cidrportal.nhs.uk/

*Please ensure you complete all the mandatory sections in order to be able to submit and process the application form. All the mandatory sections are starred *

Please note that if you are outside of the practice map area and are likely to require home visits i.e. housebound/mobility issues, then please register with a practice more local to you.

Patient's Details*

Title*

First Name*

Surname*

Previous Name(s) i.e maiden name

Date of Birth*

Place of Birth (Town and Country)*

Current Home Address*

Post Code*

Home Telephone Number

Mobile Number*

Email addressBy giving us your email and mobile details you permit us to send you emails or texts relating to your clinical care (i.e. if you request us to send you a result).

Name of Next Of Kin (Emergency Contact in the UK)

Relationship to you i.e brother, son etc

Phone Number

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

Your previous address in the UK (please advise us here also if you have no previous UK address)

Name of previous doctor (NHS GP) while at that addressThis includes the name of the GP surgery/medical centre/health centre/medical practice

Address of previous GP

If you are from abroad (please go to the section if this does not apply to you)

Your first address where you registered with a GP

If previously resident in the UK, the date of leaving

Date you first came to live in the UK (or approximate date if not known)Please ensure that you complete this section if you have come from abroad - otherwise we may not be able to process your application, especially if you have not been previously registered with an NHS GP

If you are returning from the Armed Forces (please go to the section if this does not apply to you)

Address before enlisting

Service/Personnel Number

Enlisted date

Family Health History

Have any close family members (parents, siblings, aunts, uncles and grandparents) suffered from any of the following illnesses

Heart Problems

Stroke

Diabetes

Asthma

Cancer

Other Hereditary Illnesses

If they do please give further details including who, what and the approximate age of onset?

Females Only

Are you currently pregnant? If yes please when is your due date

Date of last Cervical Smear

Where was the smear taken?

Result Details (ie normal/abnormal and please also indicate if you have had previous abnormal and the details)

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. Please tick the boxes that apply:

Any of my organs/tissues or

Kidneys

Heart

Liver

Cornea

Lungs

Pancreas

Any part of my body

At this stage we will be mainly noting your preferences internally. However, if contacted by the transplant service we would notify them of your choices and therefore by ticking a box you are confirming your agreement to the organ/tissue donation.

Please leave this section blank if you do not wish to register.

PLEASE CONTACT THE SERVICE IF YOU WISH TO REGISTER by either visiting the website www.uktransplant.org.uk or calling 03001232323

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 (by ticking yes you are confirming consent to inclusion on the NHS blood donor register)

Tick here if you have given blood in the past 3 years

At this stage we will be mainly noting your preferences internally. However, if contacted by the blood & transplant service we would notify them of your choices and therefore by ticking a box you are confirming your agreement to the organ/tissue donation.

Please leave this section blank if you do not wish to register.

PLEASE CONTACT THE SERVICE IF YOU WISH TO REGISTER by either visiting the website www.blood.co.uk or calling 03001232323

FORM COMPLETION SIGNATURE

Signature of:

Please confirm the full name of the person completing this form (this will act as your signature and in doing you are also confirming that all the information provided is accurate)*

Date completed*

Supplementary questions for all patients whom are not ordinarily resident in the UK (please go to the section if this does not apply to you)

Anybody in England can register with a GP practice & receive free medical care from the 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 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 teats 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.

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, rega

Please tick one of the following boxes

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

(B) 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.

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

NON-UK EUROPEAN HEALTH INSURANCE CARD (EHIC), PROVISIONAL REPLACEMENT CERTIFICATE (PRC) DETAILS and S1 FORMS (please go to the section if this does not apply to you)

Do you have a non-UK EHIC or PRC

Yes

If yes, please enter details from your EHIC or PRC below

Country Code

Name

Given Names

Personal Identification Number

Identification number of the institution

Identification number of the card

Expiry Date

PRC validity period (a) From

(b) To:

Please tick if you have an S1 (e.g. you are retiring to the UK or have been posted here by your employer for work or live in the UK but work in another EEA member state). Please give your S1 form to the practice staff

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 purposes of recovering your NHS costs from your home country.

Summary Care Record

You will be automatically opted in to the summary care record unless you tick the below box. This record provides basic information of allergies, medications & demographics details from the GP record to other hospitals for urgent care

CIDR (Clinical Integrated Digital Record)

This is a local digital record which contains medical and social information similar to the Summary Care Record but in addition has useful information such as upcoming appointments, test results, conditions & diagnosis. This system is used both in hospitals and general practice to improve care patients receive. Having key medical information available in an emergency can save lives.We encourage all patients to allow creation of and access to this record. Should you wish to opt out please contact the surgery.Please tick here to consent for West Hampstead Medical Centre to access the record on your behalf.

Thank you for taking the time to complete this form

Patient online access

Please tick this box if you would like to be setup for online patient access that will allow you to book appointments and request repeat perscriptions

Please tick here if you would also like the facility to be able to see your results i.e. blood test results with comments requested by your GP

VIRGIN ACTIVE 02 CENTRE FREE 3 DAY PASS

If you would like to receive a pass please tick the below box, if you are not interested please leave the box unticked/blank

YES I WOULD LIKE TO RECIEVE A PASS (By ticking this box you consent to us passing your name, telephone number and email to the club)

Patient Participation Group

Please tick if you are happy for the surgery to email/text you about developments at the surgery and Open PPG meetings (you can withdraw consent in writing at any time)

Privacy Protection

Information submitted through secure forms is used only for the purposes of processing your request. We may be in touch with you in relation to the information submitted.

All Information submitted through secure forms is secured with a private key known only to the GP practice and is accessed over a secure connection by nominated Practice staff. Our practice has a strict confidentiality policy.

This information is not shared with any third party organisations.

This information is retained for up to 28 days.

I consent to my information being used for the purposes described above and wish to submit this online form to
West Hampstead Medical Centre • 9 Solent Road, London, NW6 1TP.

Learn more about our Privacy Policy and Terms of Use. Should you have any concerns about sending your personal details using the web, please use one of the alternative methods offered by our organisation.

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Online New Adult Patient Registration

Dear Patient,

Please kindly take a few minutes to fully complete this form as best you can.

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