2024 New Patient Registration Form (GMS1)

You should only send this form if you are sure that you are eligible to join this practice. Sending this form does NOT guarantee or even imply that you will be accepted onto the practice register.

For patients who take regular medication following receipt of this form you will be contacted to attend a new patient medication review appointment at the surgery. Following this consultation your registration at the practice will then be complete. No medication will be dispensed until this appointment has been attended. Patients need to ensure that they have sufficient medication from their current GP practice BEFORE completing this form. Incomplete forms will be rejected.

Last Updated: 07/03/2024

Patient's Details

PRIVACY NOTICE AND RETENTION OF DATA

Title:

PRIVACY NOTICE

Description:

PRIVACY NOTICE

DR SALAKO & PARTNERS

DATE PROTECTION OFFICER – JANE MARLEY

What is a privacy notice?

A privacy notice is a statement that discloses some or all of the ways in which the practice gathers, uses, discloses and manages a patient’s data. It fulfils a legal requirement to protect a patient’s privacy.

Why do we need one?

To ensure compliance with the General Data Protection Regulation (GDPR), Dr Salako & Partners must ensure that information is provided to patients about how their personal data is processed in a manner which is:

- Concise, transparent, intelligible and easily accessible

- Written in clear and plain language, particularly if addressed to a child, and

- Free of charge

What is GDPR?

The GDPR replaces the Data Protection Directive 95/46/EC and is designed to harmonise data privacy laws across Europe, to protect and empower all EU citizens’ data privacy and to reshape the way in which organisations across the region approach data privacy. The GDPR came into effect on 25 May 2018.

How do we communicate our privacy notice?

At Dr Salako & Partners, the practice privacy notice is displayed on our website, through signage in the reception area(s), and in writing during patient registration (by means of a leaflet). We will:

- Inform patients how their data will be used and for what purpose

- Allow patients to opt out of sharing their data, should they so wish.

What information do we collect about you?

We will collect information such as personal details, including name, address, next of kin, records of appointments, visits, telephone calls, your health records, treatment, medications, test results, x-rays etc. and any other relevant information to enable us to deliver effective medical care.

How do we use your information?

Your data is collected for the purpose of providing direct patient care. However, we can disclose this information if it is required by law if you give consent or if it is justified in the public interest. The practice may be requested to support research but we will always gain your consent before sharing your information with medical research databases such as the Clinical Practice Research or others when the law allows.

Retention of Data

In accordance with the NHS Codes of Practice for Records Management

https://digital.nhs.uk/data-and-information/looking-after-information/data-security-and-information-governance/codes-of-practice-for-handling-information-in-health-and-care/records:management-code-of-practice-for-health-and-social-care-2016

Our Website

Privacy Notice only applies to the practice. Links to any other websites, please read their privacy notice. WE TAKE NO RESPONSIBILITY for the content of other websites.

Cookies are small text files located in browser directories. When you visit a site that uses cookies for the first time, a cookie is downloaded onto your PC. The next time you visit that site, your PC checks to see if it has a cookie that is relevant (that is, one containing the site name) and sends the information contained in that cookie back to the site. The site then ‘knows’ that you have been there before and in some cases tailors what pops up on screen to take account of that fact.

Are they good or bad?

They are beneficial because they can record preferences and store data (e.g what’s in your online shopping cart). They can make sites easier to navigate and create a more personal browsing experience. The negative aspect of cookies is that information about you, however benign, is collected and stored by a website and can be used to market services to you or shared with a third party who may wish to do the same.

WiFi

Dr Salako & Partners provides free publicly accessible WiFi. The service has been kindly provided by the NHS. Use of the WiFi service is conditional, and my making use of the WiFi provided, you are indicating your agreement to the terms.

What to do if you have any questions

Should you have any questions about our privacy policy or the information we hold about you, you can ask to speak to the Practice Manager (Mrs Marguerite Cutting) or the DPO (Jane Marley – Data Protection Officer)

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

Your previous address in UK *

Occupation

Email Address

Weight

Height

Next of Kin

NEXT OF KIN CONTACT NUMBER

Relationship to Next of Kin

Signature of Patient

Date form completed

Name of previous GP while at previous address *

Address of that GP Surgery *

SMOKING

Do you smoke ?

Yes No

If Yes, how many ? (cigarettes, cigars, tobacco etc per day)

How long have you smoked ?

IF NOW AN EX-SMOKER, HOW OLD WERE YOU WHEN YOU STOPPED SMOKING ?

PASSIVE SMOKING

Are you exposed to smoke at work ?

At home ?

ALCOHOL

For the following questions please tick the answer which best applies

Do you drink Alcohol?

Yes No

If Yes, how many units do you consume per week

DIET

Do you add salt to your food after cooking?

Yes No

Do you have a varied diet, including milk, meat, vegetables and fruit?

Yes

Other

Has your Cholesterol been checked in the last 2 years?

Yes No

EXERCISE

Do you take regular exercise?

Yes No

If Yes, what sort of exercise

How many times per week

FAMILY HISTORY

Is there any of the following conditions in your immediate family under the age of 65?

Heart Disease (heart attacks, angina)

Yes No

Stroke

Yes No

Cancer

Yes No

If yes to Cancer, what type

MEDICATION

Please give details of any regular medication you take (prescribed or otherwise)?

Please list the drugs below including current dosage

Name of drug(s)

NOMINATED PHARMACY

Patients can nominate a pharmacy for their electronic prescriptions to be sent to.

Please nominate your pharmacy below:

(This will remain your pharmacy unless you advise the surgery otherwise)

Name and address of pharmacy

ALLERGIES

Are you allergic to any substance or foods?

Yes No

If yes, please give details

PAST MEDICAL HISTORY

Please provide details of any recent hospital treatment as an inpatient, any chronic medical conditions or any recent x-ray, MRI, CT scans, mammogram or ultrasound results

IMMUNISATIONS

Please provide dates of any immunisations you have had below

ARMED FORCES VETERAN

The practice is proud to be a Veteran friendly accredited practice

Are you a Veteran?

Yes No

SUMMARY CARE RECORD - YOUR EMERGENCY CARE SUMMARY

The NHS in England is introducing the Summary Care Record which will be used in emergency care. The record will contain information about any medicines you are taking, allergies you suffer from and any reactions to medicines you have had to ensure those caring for you have enough information to treat you safely.

Your Summary Care Record will be available to authorised healthcare staff providing your care anywhere in England but they will ask your permission before they look at it. This means that if you have an accident or become ill the doctors treating you will have immediate access to important information about your health.

Your GP practice is supporting Summary Care Records and as a patient you have a choice:

Yes I would like a Summary Care Record

No I do not want a Summary Care Record (please ask for opt out form in reception)

PATIENT PARTICIPATION GROUP (PPG)

Langdon Hills Medical Centre is committed to improving the services we provide to our patients. To do this, it is important that we hear from patients about their experiences, views and ideas for making services better. The PPG gives you the opportunity to do this. If you are interested in getting involved please tick the box below and we will contact you.

Yes I would like to join the PPG

Yes

CONSENT FOR EMAIL AND TEXT MESSAGE COMMUNICATION

The practice wishes to expand its methods of communicating with patients to include the use of email and text messaging. These will never be used for urgent communications. Your contact details will be used solely in relation to health care services offered by the practice and you can choose to opt out of the services at any time by contacting your surgery.

Please indicate your consent below. Consent is required in line with new General Data Protection Regulations (GDPR).

Mobile no. - consent to use:

Yes No

SMS communication - consent to use:

Yes No

Email - consent to use:

Yes No

To refer and obtain information from third parties involved in your healthcare e.g. hospitals

Yes No

CONSENT TO DISCLOSE CONFIDENTIAL MEDICATION INFORMATION

I hereby consent to the disclosure of my private medical information to the person(s) below:

Full name, relationship to you, address, date of birth and contact telephone number

I give consent for the above named person to have the following level of authority:

Full and open ended disclosure of any matter related to my medical records

Order or collect prescriptions, referral letters, blood forms or any other correspondence on my behalf

CARER REGISTRATION FORM

Please complete below if you are an unpaid/paid carer and indicate to whom you care for (e.g. family, friend, other)

complete below:

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2024 New Patient Registration Form (GMS1)

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