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Carepoint Practice Online Registration Forms

You are required to complete the following medical questionnaire.

Once completed, please attend reception to complete the GMS1 form.

We will discard the questionaire if you do not make contact with our reception team within 10 working days.

Document Upload (Mandatory)

Upload File

Forms of ID we will accept:

  • Passport

  • UK Drivers License

If you are unable to upload ID, we will not be able to process your registration form.

GMS1 - Section 1 - Patient Details 

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GMS1 - Section 2 - Medical Records Trace

GMS1 - Section 3 - If you are from abroad

GMS1 - Section 4 - If you are returning from the armed forces

GMS1 - Section 5 - Complete Registration

If you are registering a child under 5 
If you need your doctor to dispense medicines and appliances
Signature

GMS1 - Section 6 - 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. For more information, please ask for the leaflet on joining the NHS Organ Donor Register
Please tick the boxes that apply

GMS1 - Section 7- NHS Blood Donor Registration

For more information, please ask for the leaflet on joining the NHS Blood Donor Register
I would like to join the NHS Blood Donor Register as someone who may be contacted and would be prepared to donate blood.

GMS1 - Section 8 - Supplementary Questions : Patient Declaration for all patients who are not ordinarily resident in the UK

Anybody in England can register with a GP practice and receive free medical care from that 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 a 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 tests 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. More information on ordinary residence, exemptions and paying for NHS services can be found in the Visitor and Migrant patient leaflet, available from your GP practice. 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, regardless of advance payment. The information you give on this form will be used to assist in identifying your chargeable status, and may be shared, including with NHS secondary care organisations (e.g. hospitals) and NHS Digital, for the purposes of validation, invoicing and cost recovery. You may be contacted on behalf of the NHS to confirm any details you have provided.

Patient Decleration
I declare that the information I give on this form is correct and complete. I understand that if it is not correct, appropriate action may be taken against me.

GMS1 - Section 9 - Non-UK European Health Insurance Card (EHIC), Provisional Replacement Certificate (PRC) details and S1 Forms.

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. If you are visiting from another EEA country and do not hold a current EHIC (or Provisional Replacement Certificate (PRC)/S1, you may be billed for the cost of any treatment received outside the GP practice, including at hospital).
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Please tick if you have an S1 (e.g. you are retiring to the UK or you have been posted here by your employer for work or you 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 purpose of recovering your NHS costs from your home country.

Medical Questionaire - Section 1 - Emergency Contacts

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Medical QuestionaireSection 2: Information about you (Medical History)

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If you smoke and would like help to stop smoking please contact Hillingdon Council Stop Smoking Clinic

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Have you suffered from (Please choose from below)

Medical Questionnaire - Section 3: Alcohol Screening Questionnaire

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Please add up the numbers in brackets (X) for the above x3 questions. 

If your score is above 5, please complete the remaining full audit below. If your score is below 5, please skip to section 4.

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Please add up the scores in the brackets for the above 7 questions. 

Lower risk: 0 - 7

Increasing risk: 8 - 15

Higher risk: 16 - 19

Possible dependence: 20+

 

If you score is greater than 8, you may wish to make an appointment with a GP to discuss the possible impact of alcohol on your health. 

Medical Questionnaire - Section 4: Cervical Smear Test (Females only)

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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 5: Blood Pressure Readings

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.

If you have a medical condition such as diabetes we recommend having readings below 135/85 and to do measurements every three months.  If your blood pressure is higher than this on a regular basis, although you can continue to make dietary and lifestyle changes, it is essential for you to lower it and we suggest you drop in your readings so we can analyse them. 

 

If you have no medical conditions than your readings can be below 140/90. If they are consistently above this then please make an appointment with our HCA who can look through your results and determine the next outcome. 

Medical Questionnaire - Section 6: 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. 

  1. You are aged 40 to 75 years old 

  2. You have NO pre-existing health conditions/chronic diseases (Diabetes, High blood pressure, High Cholesterol, Kidney disease)? 

  3. You have NOT had a NHS Health Check in the past 5 years? 

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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 7: 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.  

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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 8: 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 website and as a mobile app for both Android and iOS devices, 

 
With Patient Access, you can now access our services (mentioned below) at home, work or on the move — wherever you can connect to the internet. What's more, because Patient Access is a 24 hour online service you can do this in your own time, day or night. 

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  • Book an appointment. 

  • Order repeat prescriptions. 

  • Change your address details. 

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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. 

 
Children under 11 are able to have a parent/carer as a proxy user. Patients 11-18 are required to fill out a separate authorisation form.

Medical Questionnaire - Section 9: 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 to opt out. The GP practice can no longer opt you out. 

Medical Questionnaire - Section 11: National Patient Date Opt-Out

Please go to www.nhs.uk/your-nhs-data-matters for information regarding the National Patient Data Opt-Out. You can also update your preferences on the NHS website (you will need your name, date of birth & NHS Number). The GP practice can no longer opt you out.  

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.