THE LANSDOWNE SURGERY

REGISTRATION CHECKLIST UNDER 5

One pack per person

Please ensure you have received and if necessary, completed and returned the following documents:

Please tick to confirm you Lansdowne staff check have completed and enclosed (initial to confirm receipt the required form and completion) New Patient Health Check □ Requested □ Booked (use textual □ Declined appointment)

NHS registration form (GSM1) □ Yes Without this, we □ Registered on SystmOne cannot register you at The Lansdowne Surgery New patient questionnaire □ Yes □ No (Page 2 & 3)

Summary Care Record □ Requested Read Code:XaXbY Information □ Declined Read Code:XaXj6 (Page 4 &5)

Care Record Scheme □ Requested Read Code: None so far (Page 4 & 5) □ Declined Read Code: XaZ89 or XaaVL Pharmacy Information: □ ______Pharmacy □ Pharmacy nominated (Page 6) □ Collect in person Have you provided 2 forms of □ Passport □ Passport identification? □ Driving licence □ Driving licence Please select two from the (photocard) with current (photocard) with current following options address address □ Utility bill with current □ Utility bill with current address address □ Birth certificate or court order □ Birth certificate stating date of birth of child and Identification verified, copied parental responsibility and returned to patient

Office use only Initials of Receptionist carrying out check ------Date ------

1 THE LANSDOWNE SURGERY

New Patient Questionnaire

Children under 5 years old

Please visit to our web site for full details of our services www.thelansdownesurgery.co.uk

Please complete the form below to enable us to complete the registration process

First Name: ...... Yes / No

Surname: ...... If YES, what are they?………………………

D.O.B: ………………...... ………………………………………………….

Sex: Male / Female …………………………………………………

Parental responsibility: …………………………………………………

Please provide original birth certificate Has your child you ever had any of the or court order to confirm: following? (Please tick)

Mother’s Name: ...... Convulsions/fits Diabetes D.O.B: ………………...... Asthma Father’s Name: ...... Has your child ever had any other D.O.B: ………………...... serious illness, injury or operation?

Home tel. no: ……………………... Yes / No

Mobile tel. no: ……………………….. If YES, please give details ……………… Please note: This number will not be used for SMS messaging ………………………………………………….

………………………………………………… Ethnic origin (please tick): White, British Indian Is your child a carer Yes / No White, other Chinese   For whom do they care? Black African Black Caribbean a relative Pakistani Bangladeshi a friend Vietnamese Confidential a neighbour Other……………………………………... Other (please specify) First spoken language ………………... ……………………………………………… Does your child have any allergies? Please turn over for 2 more Yes / No questions and your signature Does your child have any allergies?

2 Immunisations:

Please give us details of the following immunizations your child has already been given Age due Immunisation Comments Batch no. Date given (if known) 2 months Diphtheria/Tetanus/Whooping Cough/Polio, Hib,PCV 1, Rotavirus

3 months 2nd dose Diphtheria/Tetanus/Whooping Cough/Polio, Hib, Men C, Rotavirus

4 months 3rd dose Diphtheria/Tetanus/Whooping Cough/Polio, Hib, PCV2

12-13 months Measles, Mumps, Rubella (MMR), PCV3, HibMen C

2 – 4 years Flu vaccination (nasal spray)

3 – 5 years Pre-school booster Diphtheria/Tetanus/Polio, MMR2

Please list any other immunisations given (e.g. BCG at birth)

Housing

What type of housing does your child live in? Please tick

 House …………………………………………………  Bungalow Date: …………………….  Mobile home  Bedsit  Upper floor flat  Ground floor flat Parent’s/Guardian’s name (Print):  Lodgings ………………………………………… …….  Temporary

Parent/Guardian’s signature:  Confidential  Homeless

3 THE LANSDOWNE SURGERY

We offer our patients the choice of sharing their medical information with a variety of outside agencies. There are currently 3 ways in which your information could be shared.

At the end of this section, is a form for you to indicate your preferences for sharing your records: please use it and return with this registration pack, to the Receptionist.

SHARING RECORDS WITH OTHER PROVIDERS OF PATIENT CARE

Many patients think that their GP record is available to any other clinicians that they may come into contact with, for their clinical care. This is not the case and at present your GP medical record is kept within the Practice.

By agreeing to share your record outside the practice, the intention is to help other to give you safe, timely & effective treatment. Clinicians will only be allowed to access your record if they are authorised to do so & even then, only if you give your express permission. These clinicians could be working in A & E Departments, ‘Out of Hours’ health services, hospices, community teams such as district nurses and the local hospitals – RUH, Great Western Hospital and Salisbury District Hospital.

You will be asked if healthcare staff can look at your medical record every time they need to, unless it is an emergency: for instance if you are unconscious. You can refuse on each occasion, if you think access is unnecessary.

NHS SUMMARY CARE RECORD

The Summary Care Record has been introduced to help deliver better and safer care & give you more choice about with whom you share your healthcare information. By agreeing to share your record outside the practice, the intention is to help other to give you safe, timely & effective treatment. Clinicians will only be allowed to access your record if they are authorised to do so & even then, only if you give your express permission. The Summary Care Record contains basic information about:

 any allergies you may have,  unexpected reactions to medications,  & any prescriptions you have recently received.

If you are the parent or guardian of a child under 16, then please either make this information available to them or decide & act on their behalf.

You do not have to have a Summary Care Record, although you are strongly recommended to consider this choice. If you are happy for a Summary Care Record to be set up for you then you need take no further action.

For more information visit www.nhscarerecords.nhs.uk or telephone 0300 123 3020.

CARE RECORD SCHEME

4 This allows your information to be used by Health & Social Care Information Centre (HSCIC) This system uses information such as your postcode & NHS number, but not your name, to link your records in a secure system, so your identity is protected. Information which does not reveal your identity can then be used by others, such as researchers and those planning health services, to make sure we provide the best care possible for everyone. How your information is used and shared is controlled by law and strict rules are in place to protect your privacy. It is considered important that the NHS can use this information to plan & improve services for all patients. The Government would like to link information from all the different places where you receive care, such as here, hospitals & community service. This will allow comparison of the care you received in one area against the care you received in another, so they can see what has worked best.

You have the right to prevent confidential information about you from being shared or used for any purpose other than providing your care, except in special circumstances, such as if you suffer from a notifiable disease, such as food poisoning. If you do not want information that identifies you to be shared outside your GP practice, please complete the opt-out declaration overleaf and we will make a note of this in your medical record. This will prevent your confidential information being used other than where necessary by law, (for example, if there is a public health emergency) It will also prevent the identifiable information held in your GP record from being sent to the HSCIC secure environment & prevent those who have gained special legal approval from using your health information for research.

Even if you allow your data to be sent to HSCIC you can also object to any information containing data that identifies you from leaving the HSCIC secure environment. This includes information from all places you receive NHS care, such as hospitals. If you object, confidential information will not leave the HSCIC & be used in this way, except in very rare circumstances for example in the event of a civil emergency. If you want more information about this service, please go to: www.nhs.uk/caredata

Please see overleaf for consent/dissent form for completion:

SHARING OF YOUR MEDICAL INFORMATION: CONSENT FORM

5 SHARING RECORDS WITH OTHER PROVIDERS OF PATIENT CARE

 I am happy to share my record with the other care providers for the sole purpose of my continued clinical care. I understand that I will be asked if healthcare staff can look at my medical record every time they need to, unless it is an emergency and that I can refuse on each occasion, if I think access is unnecessary.

 I am not happy to share my medical record with other care providers and wish this to be recorded on my notes.

SUMMARY CARE RECORD

 I wish a summary care record to be created

 I do not wish to have a Summary Care Record created, having read the information overleaf about the Summary Care Record

CARE RECORD SCHEME (please tick any or all statements)

 I agree to anonymous information being sent to HSCIC for any purpose  I do not wish for any of my medical record to leave my GP practice This will prevent the identifiable information held in your GP record from being sent to the HSCIC secure environment. It will also prevent those who have gained special legal approval from using your health information for research. (Read Code: XaZ89)  I do not wish for any data that identifies me from leaving the HSCIC secure environment , although I agree to information from my GP record being sent to HSCIC (Read Code: XaaVL)

YOUR NAME: DATE OF BIRTH:

SIGNED: DATE:

NAME OF CHILD: DATE OF (If signed on behalf of a BIRTH: child under 16) SIGNED: DATE:

PHARMACY INFORMATION

6 What is the NHS Electronic Prescription Service? Prescriptions in England are going paperless and we want to make it as easy as possible for you to get your prescription. So instead of your GP giving you a prescription on paper, we can electronically send it straight to a pharmacy of your choice as part of the NHS Electronic Prescription Service. You can choose to have your prescriptions sent to any pharmacy offering the service. The Practice can arrange for your prescription to be sent to a number of participating pharmacies in the area. Please let the surgery know which pharmacy you have chosen, by ticking the appropriate box at the bottom of the page You may find this service particularly beneficial if you receive regular prescriptions. This service will mean you don't have to collect your repeat prescription from your GP surgery between check-ups. The service can be used for repeat prescriptions &/or one-off prescriptions. The service cannot be used for:

 Private prescriptions

 Prescriptions for controlled drugs

 A few other more unusual items, such as feeds and some creams

The chemists to whom we can send Electronic Prescriptions are listed below. Please indicate by ticking the list, if you would like to use this service:

□ Rowlands, Little Brittox, Devizes

□ Boots Pharmacy, Little Brittox, Devizes

□ Morrisons Pharmacy, Estcourt Road, Devizes

□ Lloyds Pharmacy, Trowbridge

□ Day Lewis Pharmacy, Market Lavington

PATIENT NAME: ______

PATIENT DATE OF BIRTH: ______

7 8 9 THE LANSDOWNE SURGERY Accessing GP Records Online Key considerations - Patient Information Leaflet Forgotten history Practices are increasingly enabling patients to be able to request repeat prescriptions and book appointments There may be something you have forgotten online. about in your record that you might find upsetting. From the 1st April 2016 the Practice will enable patients to view certain elements of their medical record. This Abnormal results or bad news information includes: If your GP has given you access to test results or ←- Blood Pressure Readings - Call Recalls letters, you may see something that you find upsetting to you. This may occur before you have ←- Care Plans - Diagnoses spoken to your doctor or while the surgery is closed and you cannot contact them. ←- Drugs - Drug Sensitivities Choosing to share your information with ←- Pathology Requests - Referral Ins/Outs someone

←- Pathology Reports - Vaccinations It’s up to you whether or not you share your information with others – perhaps family members - Problem Headers - Repeat Drugs ← or carers. It’s your choice, but also your responsibility to keep the information safe and ← secure. However this requires additional consideration as outlined in this leaflet. You will be asked that you have Coercion read and understood this leaflet before consenting and applying to access your records online. The practice If you think you may be pressured into revealing will also need to verify your identity and you should details from your patient record to someone else bring two forms of ID when applying for access - one of against your will, it is best that you do not register which should be photographic – eg a passport or for access at this time. driving licence. Misunderstood information Please note:  It will be your responsibility to keep your Your medical record is designed to be used by login details and password safe and clinical professionals to ensure that you receive secure. If you know or suspect that your the best possible care. Some of the information record has been accessed by someone that within your medical record may be highly you have not agreed should see it, then you technical, written by specialists and not easily should change your password immediately. understood. If you require further clarification, please contact the surgery for a clearer  If you can’t do this for some reason, we explanation. recommend that you contact the practice so that they can remove online access until Information about someone else you are able to reset your password. If you spot something in the record that is not  If you print out any information from your about you or notice any other errors, please log record, it is also your responsibility to keep out of the system immediately and contact the this secure. If you are at all worried about practice as soon as possible. keeping printed copies safe, we recommend that you do not make copies at More Information all. A helpful leaflet about the security of your  The practice may not be able to offer online health care record is available at: access for a number of reasons such as concerns that it could cause harm to www.nhs.uk/NHSEngland/thenhs/heatlhrecords/ physical or mental health or where there is reference to third parties. Documents/PatientGuidanceBooklet.pdf 10  The practice has the right to remove online access to services for anyone that doesn’t use them responsibly.

THE LANSDOWNE SURGERY

Once a patient reaches the age of 12 years old, all Proxy access is automatically removed, unless a separate application has been made for this to continue. This is in line with BMA guidance and is designed to protect patient confidentiality at the recognised age of competency.

Please speak to the patient’s GP if you wish to reapply for access, beyond this age.

Consent to proxy access to GP online services Proxy access allows someone other than the patient to access Online Services on a patient’s behalf. Generally, the patient will need to give consent for this to happen. Section 1 is completed by the patient if they are over 12 and have capacity to consent Section 2 is completed by the patient, outlining which services this proxy will be able to use. Section 3 is completed by the person wanting to access the patient’s record Section 4 (overleaf) asks for full details of the patient and the person asking for proxy access Note: If the patient does not have capacity to consent to grant proxy access and proxy access is considered by the practice to be in the patient’s best interest section 1 of this form may be omitted.

Section 1

I,………………………………………………….. (name of patient), give permission to my GP practice to give the following people ….………………………………………………………………..…………….. proxy access to the online services as indicated below in section 2. I reserve the right to reverse any decision I make in granting proxy access at any time. I understand the risks of allowing someone else to have access to my health records. I have read and understand the information leaflet provided by the practice

Signature of patient Date

Section 2

Online appointments booking  Online prescription management  Accessing the summary record ( allergies, medication only)  Accessing the Coded Medical Record 

11 Section 3

I/We…………………………………………………………………………….. (names of representatives) wish to have online access to the services ticked in the box above in section 2 for ……………………………………….……… (name of patient). I/We understand my/our responsibility for safeguarding sensitive medical information and I/We understand and agree with each of the following statements:

I/We have read and understood the information leaflet provided by the practice and  agree that I will treat the patient information as confidential I/We will be responsible for the security of the information that I/we see or download  I/We will contact the practice as soon as possible if I/we suspect that the account has  been accessed by someone without my/our agreement If I/We see information in the record that is not about the patient, or is inaccurate, I/we  will contact the practice as soon as possible. I will treat any information which is not about the patient as being strictly confidential

Signature/s of representative/s Date/s

Section 4: The patient (This is the person whose records are being accessed)

Surname Date of birth First name Address

Postcode

Email address Telephone number Mobile number The representatives (These are the people seeking proxy access to the patient’s online records, appointments or repeat prescription.)

Surname Surname First name First name Date of birth Date of birth Address Address (tick if both same address )

Email Email Telephone Telephone Mobile Mobile For practice use only The patient’s NHS number: Method of verification Photo ID and proof of residence  Identity verified by Date Vouching  (initials) Vouching with information in record 

12 Proxy access authorised by: Date:

Date account created: Date password sent: Level of record access enabled: Notes / comments on proxy access Prospective  Retrospective  All  Limited parts  Contractual minimum  Patient’s record amended under Special Notes to show names of proxy representative, date of proxy agreement and who agreed this Proxy representative’s record marked under Special Notes, to show to whose record they have access (if registered on SystmOne)

13