New Patient - The Ridge Medical Practice Bradford, West Yorkshire

PLEASE NOTE: If you take any regular medications, you will need to provide a copy of your current repeat prescription slip in order to continue to receive them. Electronic prescriptions are the safest way to deal with your medication. Do you wish us to nominate The Ridge Pharmacy for all your electronic prescription? *

Yes

No

Title *

Mr

Mrs

Miss

Ms

First Name *

Surname *

Date of Birth *

Phone Number *

Email Address *

Address Line 1 *

Address Line 2

Town

City *

Postcode *

Please help us trace your previous medical records by providing the following information – your previous address in the UK *

Name of previous GP practice while at that address *

Address of previous GP Practice *

If you are from abroad – Your first UK address where registered with a GP *

If previously resident in UK, date of leaving *

Date you first came to live in the UK *

Were you ever registered with an Armed Forces GP – please indicate if you have served in the UK Armed Forces and/or been registered with a Ministry of Defence GP in the UK or overseas:

Regular

Reservist

Veteran

Family Member (Spouse, Civil Partner, Service Child)

Address before enlisting

Service or Personnel number

Enlistment date

Discharge date

Footnote: These questions are optional and your answers will not affect your entitlement to register or receive services from the NHS but may improve access to some NHS priority and service charities services.

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

Signature confirming my consent to join the NHS Organ Donor Register

Date

Please tell your family you want to be an organ donor. If you do not want to be an organ donor, please visit www.organdonation.nhs.uk or call 0300 123 23 23 to register your decision

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

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

Signature confirming my consent to join the NHS Organ Donor Register

Date

My preferred address for donation is: (only if different from above, e.g. your place of work) including postcode

All blood types are needed, especially O negative and B negative. Visit www.blood.co.uk or call 0300 123 23 23

Sharing out – this controls whether your full electronic patient record can be shared with other NHS care services where you are treated. Please record your preference

Yes (shareable)

No (not shareable)

What is your preferred spoken language? *

Sharing in – this controls whether you agree for this practice to view information you’ve agreed to share at other NHS care services. Please record your preference:

Yes (viewable)

No (not viewable)

Are you currently pregnant? *

Yes

No

If yes, how many weeks?

Due date (if known)

I wish to have access to the following online services (please select all that apply):

Booking appointments

Requesting repeat prescriptions

Accessing my medical record (If you are newly registered to the practice this access will only be given once your medical records have been summarised)

Upload Photo ID *

Maximum upload size: 2.1MB

Please list below any special requirements you think we should be aware of when contacting you

Disability – tick all that apply *

Are you a Carer? *

Yes – if yes, please complete Carer card at reception

No

Do you have a Carer? *

Yes – if yes please complete Carer card at reception

No

Ethnicity – tick 1 box *

Smoking status – tick one box only *

Smoker

Ex-smoker

E-Cig smoker

Never smoked

Do you drink alcohol? *

Yes

No

If yes, please answer 3 questions below

How often do you have a drink containing alcohol?

Hoe many of units of alcohol do you drink on a typical day when having a drink?

How often have you had 6 or more units if female or 8 or more units if male, on a single occasion in the last year?

How much exercise do you consider yourself as doing?

None

Light

Moderate

Extensive

Height

Weight

Occupation

Signed (or legal guardian if under 16)

Date

Important Information – Please read before returning this form

You can now use the internet to book GP appointments and request your repeat prescriptions. You can also view your medical record.

It will be your responsibility to keep your login details and password safe and secure. If you know or suspect that your record has been accessed by someone that you have not agreed should see it, then you should change your password immediately.

If you can’t do this for some reason, we recommend that you contact the practice so that they can remove online access until you are able to reset your password.

If you print out any information from your record, it is also your responsibility to keep this secure. If you are at all worried about keeping printed copies safe, we recommend that you do not make copies at all.
Before you apply for online access to your record, there are some other things to consider.

Although the chances of any of these things happening are very small, you will be asked that you have read and understood the following before you are given login details.

Forgotten History

There may be something you have forgotten about in your record that you might find upsetting.

Abnormal results or bad news

If your GP has given you access to test results or letters, you may see something that you find upsetting to you. This may occur before you have spoken to your doctor or while the surgery is closed and you cannot contact them.

Choosing to share your information with someone
It’s up to you whether or not you share your information with others – perhaps family members or carers. It’s your choice, but also your responsibility to keep the information safe and secure.

Coercion

If you think you may be pressured into revealing details from your patient record to someone else against your will, it is best that you do not register for access at this time.

Misunderstood information

Your medical record is designed to be used by clinical professionals to ensure that you receive the best possible care. Some of the information within your medical record may be highly technical, written by specialists and not easily understood. If you require further clarification, please contact the surgery for a clearer explanation.

Information about someone else

If you spot something in the record that is not about you or notice any other errors, please log out of the system immediately and contact the practice as soon as possible.

DISCLAIMER

The Ridge Medical Practice cannot be held responsible for text messages sent to a mobile telephone number you have provided which no longer belongs to you or if someone has access to your mobile and can view your messages. We further recommend you do not smoke, drink alcohol within national guidelines and exercise regularly.

I wish to access my medical record online and understand and agree with each statement below:

Checkboxes

I will be responsible for the security of the information that I see or download

Checkboxes

If I choose to share my information with anyone else, this is at my own risk

Checkboxes

I will contact the practice as soon as possible if I suspect that my account has been accessed by someone without my agreement

Checkboxes

If I see information in my record that is not about me, or is inaccurate I will log out immediately and contact the practice as soon as possible

Checkboxes

If I see information in my record that is not about me, or is inaccurate I will log out immediately and contact the practice as soon as possible

Patient choices regarding sharing of health records

Electronic records are kept in all the places where you receive healthcare. Often, NHS care services can usually only share information from those records by letter email, fax or phone. At times, this can slow down your treatment and mean information is hard to access.

This service uses a secure computer system that allows the sharing of full electronic records across different NHS care services. This form is not about your Summary Care Record (SCR), it is asking your sharing preferences regarding your full detailed electronic record.

We are telling you about this, as you have a choice to make. You can choose to share or not to share your full electronic record with other NHS care services where you are treated and whether we can view records held by those other services.

If you choose to make your record shareable, your clinical details will only viewable by clinical teams who are treating you. Each clinical team which cares for you now or in the future will ask your permission to view your shared record. You can also ask for part of your record to be made private – not shareable. All record accesses are recorded and auditable.

If you choose not to make your records shareable, we will respect your wishes and will do our best to make your care safe and efficient. However, denying the clinical teams caring for you the ability to access important clinical details could compromise your care.

If you require further information please ask at reception. You can also visit the NHS Care records website or download the NHS Care Record Guarantee.