Please ensure you:
Attach GMS1 form
Attach Proof of identity
Have a recent blood pressure, height & weight reading
GMS1 Form (Required) Please fill out the following document and fill out the details. (You are able to type in to the PDF).
Please save as and attach below.
Click above for GMS1 form
Personal Identification (Required) Please upload a form of personal identification. Such as your passport or drivers license.
Medical Questionnaire - Section 1: Your Details Have you been in the country for more than 5 years? Are you the main carer for someone with a chronic health disability who is dependent on you?
Medical Questionnaire - Section 2.1: Ethnicity
Medical Questionnaire - Section 2.2: Smoking Screening If you have selected 'No', please skip to section 2.3
Medical Questionnaire - Section 2.3: Alcohol Screening If you have selected 'No', please skip to section 2.4
How often do you have a drink containing alcohol? How many units of alcohol do you drink on a typical day when you are drinking? How often have you had 6 or more units if female, or 8 or more if male, on a single occasion in the last year? Please add up your score in brackets. If you score is below 5, please skip to question 2.4.
How often during the last year have you found that you were not able to stop drinking once you had started? How often during the last year have you failed to do what was normally expected from you because of your drinking? How often during the last year have you needed an alcoholic drink in the morning to get yourself going after a heavy drinking session? How often during the last year have you had a feeling of guilt or remorse after drinking? How often during the last year have you been unable to remember what happened the night before because you had been drinking? Have you or somebody else been injured as a result of your drinking? Has a relative or friend, doctor or other health worker been concerned about your drinking or suggested that you cut down?
Medical Questionnaire - Section 2.4: Physical Health Using a blood pressure machine (home or pharmacy), please take your blood pressure readings and note below. If you do not have a blood pressure machine at home, please skip this question & visit reception where we have a machine in the waiting room at your earliest convenience.
Medical Questionnaire - Section 2.5: Medical History Please list any Chronic or Serious illnesses, accidents or operations/admissions to hospital with dates and details. Please also list and present illnesses you may have and/or any ongoing hospital consultations/treatments.
Do you have a learning disability? Please list any medicines (including over the counter) being taken, the amountant & whom it was started by. (We will require proof to be shown at reception or emailed before we are able to carry on prescribing).
Are you allergic or sensitive to any medicines / food / animals etc? - If so, please state which?
Medical Questionnaire - Section 2.5: Family History Family History - Tick if you have any first degree family members who have been diagnosed with the following:
Medical Questionnaire - Section 3: Cervical Smear Test (Females only) Have you had a cervical (cancer) smear test? Have you had a hysterectomy? If you would like to opt out from the cervical screening programme, please visit our website & fill out the informed consent for withdrawal form, alternatively please speak to a member of our reception team.
Medical Questionnaire - Section 4: Free NHS Health Check We carry out NHS Health Checks on anyone who is eligible (see below). This can be considered a 'MOT' to give you guidance about your health.
You will be eligible if you meet all of the following criteria, if unsure please ask one our health advisers who will be happy to answer your questions.
You are aged 40 to 75 years old
You have NO pre-existing health conditions/chronic diseases (Diab etes, High blood pressure, High Cholesterol, Kidney disease)?
You have NOT had a NHS Health Check in the past 5 years?
Do you meet the NHS Health Check eligibility? If you meet the eligibility, then you are eligible for an NHS Health Check. Please inform the receptionist so an appointment can be booked with the Health Care Assistant.
Medical Questionnaire - Section 5: Electronic Prescription Service The Electronic Prescription Service (EPS) is an NHS service. It gives you the chance to change how your GP sends your prescription to the place you choose to get your medicines or appliances from. If you want to use EPS ask someone at your GP surgery or at any pharmacy or dispensing appliance contractor that offers EPS to add your nomination for you. Nomination means you choose a place for your GP practice to electronically send your prescription to. You don't need a computer to use EPS. For more information, please visit our website.
Would you like to set up EPS? If you have ticked yes for the Electronic Prescription Service & the nomination above is left blank, we will automatically nominate you to the closest pharmacy to your address.
Medical Questionnaire - Section 6: Online Access At Carepoint Practice, we aim to offer everyone in our care a high quality service and therefore we have made patient access available to all our patients. This is available through the Patient.info
Book an appointment.
Order repeat prescriptions.
Change your address details.
Would you like to sign up for Online Access? If you have selected yes, you will be texted an online linkage key within 10 working days of you registering. If you have not received the text, please call reception.
Medical Questionnaire - Section 7: Out of Area If you live more than 1km away from our practice postcode, please be aware that we will no longer be able to visit you if you are unable to attend the practice. This may make it more difficult for you to access medical help when you are not well. It is not the responsibility of the practice to arrange for another doctor to visit you in these circumstances.
Should you still wish to remain registered at the practice under these terms then please complete the section below (child’s questionnaire can be completed by parents)
I wish to remain registered at the practice and accept that I will not be able to ask for a home visit at my address and that the practice will not be responsible for arranging this help for me if required
Medical Questionnaire - Section 10: Summary Care Records Request for all clinical data to be withheld from the summary care record
What does it mean if I DO NOT have a summary care record?
Health-care staff treating you may not be aware of your current medications in order to treat you safely and effectively. Health-care staff treating you may not be made aware of current conditions and/or diagnoses leading to a delay or missed opportunity for correct treatment. Health-care staff may not be aware of any allergies/adverse reactions to medications and may prescribe or administer a drug/treatment with adverse consequences.
Questions
If you have any questions or if you wish to discuss your choices or concerns, please telephone the NHS Care Records Service Information Line on 0845 603 8510. If you remain unsure about whether or not to have a SCR please speak to reception.
I DO NOT want to share my clinical data
Please go to www.nhs.uk/your-nhs-data-matters
Medical Questionnaire - Section 11: National Patient Date Opt-Out Please go to www.nhs.uk/your-nhs-data-matters
Thank you for submitting the online registration for Carepoint Practice. It may take us up to 5 working days to register you. If you have not heard from us by then, please call us.
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