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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
have completed and enclosed
the required form
□ Requested
□ Declined
Lansdowne staff check
(initial to confirm receipt
and completion)
□ Booked (use textual
appointment)
□ Yes
Without this, we
cannot register you at The
Lansdowne Surgery
□ Yes
□ No
□ Registered on SystmOne
Summary Care Record
Information
(Page 4 &5)
□ Requested
□ Declined
Read Code:XaXbY
Read Code:XaXj6
Care Record Scheme
(Page 4 & 5)
□ Requested
□ Declined
Pharmacy Information:
(Page 6)
□
□
□
□
Read Code: None so far
Read Code: XaZ89 or
XaaVL
□ Pharmacy nominated
New Patient Health Check
NHS registration form (GSM1)
New patient questionnaire
(Page 2 & 3)
Have you provided 2 forms of
identification?
Please select two from the
following options
_______ Pharmacy
Collect in person
Passport
Driving licence
(photocard) with current
address
□ Utility bill with current
address
□ Birth certificate or court order
stating date of birth of child and
parental responsibility
□ Passport
□ Driving licence
(photocard) with current
address
□ Utility bill with current
address
□ Birth certificate
Identification verified, copied
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:
……………….............
………………………………………………….
Male / Female
…………………………………………………
Sex:
Parental responsibility:
…………………………………………………
Please provide original birth certificate
or court order to confirm:
Has your child you ever had any of the
following? (Please tick)
Mother’s Name:
..................................
D.O.B:
……………….............
Father’s Name:
..................................
D.O.B:
……………….............
Home tel. no:
……………………...
Mobile tel. no:
………………………..
Please note: This number will not be used
for SMS messaging

Convulsions/fits
Diabetes
Asthma

Has your child ever had any other
serious illness, injury or operation?
Yes / No
If YES, please give details ………………
………………………………………………….
…………………………………………………
Ethnic origin (please tick):
White, British
Indian
White, other
Chinese
Black African
Black Caribbean
Pakistani
Bangladeshi
Vietnamese
Confidential
Other……………………………………...
First spoken language ………………...
Does your child have any allergies?
Yes / No
Does your child have any allergies?
Is your child a carer
Yes / No
For whom do they care?
a relative
a friend
a neighbour
Other (please specify)
………………………………………………
Please turn over for 2 more
questions and your signature
2
Immunisations:
Please give us details of the following immunizations your child has already been given
Age due
Immunisation
Comments
Batch no. Date
(if known) given
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
Date:
…………………….
 Bungalow
 Mobile home
 Bedsit



 Upper floor flat
Parent’s/Guardian’s name (Print):
 Ground floor flat
……………………………………………….

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.
4
CARE RECORD SCHEME
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:
5
SHARING OF YOUR MEDICAL INFORMATION: CONSENT FORM
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:
(If signed on behalf of a
child under 16)
SIGNED:
DATE OF
BIRTH:
DATE:
6
PHARMACY INFORMATION
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
THE LANSDOWNE SURGERY
Accessing GP Records Online Patient Information Leaflet
Key considerations
Forgotten history
Practices are increasingly enabling patients to be able
to request repeat prescriptions and book appointments
online.
From the 1st April 2016 the Practice will enable
patients to view certain elements of their medical
record. This information includes:
- Blood Pressure Readings
- Care Plans
- Drugs
- Pathology Requests
- Pathology Reports
- Problem Headers
- Call Recalls
- Diagnoses
- Drug Sensitivities
- Referral Ins/Outs
- Vaccinations
- Repeat Drugs
However this requires additional consideration as
outlined in this leaflet. You will be asked that you have
read and understood this leaflet before consenting and
applying to access your records online. The practice
will also need to verify your identity and you should
bring two forms of ID when applying for access - one
of which should be photographic – eg a passport or
driving licence.
Please note:
 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.
 The practice may not be able to offer online
access for a number of reasons such as
concerns that it could cause harm to
physical or mental health or where there is
reference to third parties.
 The practice has the right to remove online
access to services for anyone that doesn’t
use them responsibly.
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.
More Information
A helpful leaflet about the security of your
health care record is available at:
www.nhs.uk/NHSEngland/thenhs/heatlhrecords/
Documents/PatientGuidanceBooklet.pdf
8
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




9
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
First name
Address
Date of birth
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
First name
Date of birth
Address
Surname
First name
Date of birth
Address (tick if both same address )
Email
Telephone
Mobile
Email
Telephone
Mobile
10
For practice use only
The patient’s NHS number:
Identity verified by
(initials)
Date
Method of verification
Photo ID and proof of residence

Vouching

Vouching with information in record 
Proxy access authorised by:
Date account created:
Date password sent:
Level of record access enabled:
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)
Date:
Notes / comments on proxy
access
11