New patient Additional Information - Thornbury Road Centre for Health

To ensure we can provide you with the best possible care, we would like to gather a bit more information.

Please note that 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 services:

Name

First Last

Date of birth

Day

Month

Year

Country of birth Optional

Contact Number

NHS Number (if known) Optional

Enter Email Confirm Email

We will use your mobile number to send appointment reminders and health promotion details.

I do wish to receive these messages Optional

I do not wish to receive these messages Optional

Click here for our Text message/email OPT-IN information.

How would you prefer us to contact you?

Letter Optional

Email Optional

SMS (text) Optional

Phone Optional

Are you completing this form for a child under 16 years old?

Yes Optional

No Optional

Please note that 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 or service charities services.

Are you homeless?

Yes Optional

No Optional

What is your current immigration status?

Asylum Seeker Optional

Failed Asylum Seeker Optional

British citizen Optional

Other Optional

Countries lived in for more than 6 months during the past 5 years. Optional

Are you housebound?

Yes Optional

No Optional

Further Information

Do you have a ‘Living Will’ or ‘Advanced Directive’?

Yes Optional

No Optional

An advance decision (sometimes known as an advance decision to refuse treatment, an ADRT, or a living will) is a decision you can make now to refuse a specific type of treatment at some time in the future.

Have you nominated someone who has Power of Attorney or been assigned a Personal Welfare Deputy?

Yes Optional

No Optional

About You (Parent or Guardian)

Name of adult registering the child

First Optional Last Optional

Relationship to Child Optional

Are you registered or registering at this practice?

Yes Optional

No Optional

Who has legal parental responsibility? Optional

Do you consent to be contacted by SMS?

Yes Optional

No Optional

Do you consent to be contacted by email?

Yes Optional

No Optional

It would be helpful to get your child’s birth certificate as this helps to show who may hold parental responsibility do please upload the birth certificate below. Optional

Max. file size: 1 GB.

Upload vaccination here

Next of Kin / Name of person(s) with legal parental responsibility

Name

First Optional Last Optional

Gender

Female Optional

Male Optional

Other Optional

Please list other residents at your home. Are they registered with us? Optional

Please state name, relationship to child & if they are registered with us.

Private Caring Arrangements

Is your child being looked after by a friend, neighbour in their home?

Yes Optional

No Optional

Is someone looking after your child at home?

Yes Optional

No Optional

Relationship to you Optional

Please tick if your child is currently

Homeless Optional

A refugee Optional

An asylum seeker Optional

None of the above Optional

Is your child currently housebound?

Yes Optional

No Optional

Is the child a ‘child looked after’ under the care of the local authority?

Yes Optional

No Optional

Is your child or family currently involved with Children’s Social services or have they ever been known to Children’s Social services or the safeguarding team?

Yes Optional

No Optional

Your Child’s Background Information. Due to government policy, we are obliged to ask you the following:

Do you need an interpreter?

Yes Optional

No Optional

Please state below Optional

Your Child’s Medical Background

Please provide details of any medication your child takes (including the contraceptive pill): Optional

Please state the name of medication, dosage & frequency

Immunisation History

For children under 16, we require a copy of their vaccination records in order to complete their registration.

For children under 16, we require a copy of their vaccination records in order to complete their registration. Optional

Max. file size: 1 GB.

If your child has had vaccinations abroad or privately, you will need to send us a copy of their vaccination record so please upload here.

Parent/Guardian permission given

Permission given for someone other than a Parent/Guardian to accompany your child to an appointment?

Yes Optional

No Optional

E.g. Grandparent, Nanny, childminder

Online Services

NHS App is a secure and easy way to access a range of NHS services on your smartphone or tablet. Through the app, you can:

View parts of your medical records
Order repeat prescriptions
Book and manage GP appointments
Check symptoms and get health advice
View COVID-19 vaccination status
Access organ donation preferences
See hospital referrals, appointments, and information from other healthcare organisations

The practice often communicates with patients via the NHS app so once is all set please turn on your notifications to receive updates from us.

To set up and log in to your NHS account so please visit to get started. www.nhs.uk/nhs-app/about-the-nhs-app

Sharing Data – 3 types to share your data

1 – Full Medical Records – SystmOne record sharing

What is SystmOne?

Different healthcare providers use different computer systems to record and manage your health information. At this GP practice, we use a secure system called SystmOne. Many local NHS services also use SystmOne, including community healthcare providers like district nurses and mental health teams.
Because we use the same system, it allows relevant professionals involved in your care to view and share important parts of your medical record securely. This helps improve the coordination, safety, and quality of your care. You can choose whether or not your information is shared in this way.

There are two types of consent you can give:

Sharing Out

This means you allow the information recorded at our practice to be made available to other NHS services that use SystmOne (e.g., hospitals, out-of-hours services).

Do you consent to the sharing of data recorded here with any other organisations that may care for you?

Yes – share data with other organisations

No – do not share any data recorded here

Sharing In

This means you allow us to view information recorded by other NHS services that use SystmOne.

Do you consent to the viewing of data by this organisation that is recorded at other care services that may care for the patient where the patient where the patient has agreed to make the data sharable?

I consent

I do NOT consent

2 – Summary Care Records

Sharing your Summary Care Record

Your GP surgery shares your important healthcare information with other healthcare professionals in England when they provide you with direct care, such as emergency care or referral to a specialist service. This is called a Summary Care Record (SCR).

Why we share your information

Your SCR is shared with healthcare professionals to ensure the quality and safety of your care. This reduces the risk of things like adverse medical reactions or delays in urgent care.

What information is shared

Your SCR contains details of your:

medicines
allergies and adverse reactions
illnesses and health problems
past operations and vaccinations

Your rights

When you register with our practice, a summary care record will automatically be created for you.

You can choose not to share your SCR. However, this will mean healthcare professionals will not have access to important information about your healthcare.

If you do not want to share your SCR, or you have previously chosen not to share your SCR and have changed your mind, please fill this form online and we will change this for you:
https://www.thornburymedicalpractice.co.uk/register-your-type-1-opt-out-preference/.

If you are happy with your SCR being shared you do not need to do anything.

3 – National Data Sharing records

Under the General Data Protection Regulations (GDPR), we have a responsibility to keep your medical records confidential. We need your consent to share this with other authorised health professionals involved in your care or in planning your care. You can find more information on the website at NHS: Your Data Matters

Please see the privacy notice on our website for more information on how your data is held and used by the practice.

The NHS wants to make sure you and your family has the best care now and in the future. Your health and adult social care information supports your individual care. It also helps us to research, plan and improve health and care services in England.

There are very strict rules on how this data can and cannot be used, and you have clear data rights. We are committed to keeping patient information sate and will always be clear on how it is used.

You can choose whether or not your confidential patient information is used to research and planning.

If you do not wish your information to be used in this way please opt-out by visiting NHS: Your Data Matters or by calling 0300 303 5678. The practice is unable to record this for you.

Thank you for completing this form

Please see our practice website for further information about our team/services.