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) 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
GMS1 - Section 2 - Medical Records Trace
GMS1 - Section 3 - If you are from abroad If previously resident in UK, date of leaving Date you first came to live in the UK
GMS1 - Section 4 - If you are returning from the armed forces
GMS1 - Section 5 - Complete Registration
If you are registering a child under 5 I wish the child above to be registered with the named doctor for Child Health Surveillance
If you need your doctor to dispense medicines and appliances I live more than 1 mile in a straight line from the nearest chemist
I would have serious difficulty in getting them from a chemist
Signature Signature on behalf of patient
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. Tick here if you have given blood in the last 3 years
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.
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. Are you a parent or guardian, filling out this form on behalf of a child under 16?
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). Do you have a non-UK EHIC or PRC 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
Medical Questionaire - Section 2: Information about you (Medical History) If you smoke and would like help to stop smoking please contact Hillingdon Council Stop Smoking Clinic
Please list any 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.
Have you suffered from (Please choose from below)
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 3: Alcohol Screening Questionnaire Do you drink Alcohol - If 'No' Please skip to section 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 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.
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? 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) 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 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.
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 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.
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 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
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 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
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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