Lavender Hill Patient Registration Form - for ADULTS

This is the Lavender Hill Group Practice Registration Form for anyone older than 16 years. The online form is free-text and should therefore be compatible with translation, text-resizing, text reading and many other accessibility adjustments that can be made to the site in it's entirety. If you need the information presented here in another format, please get in touch with the practice. Fields marked "REQUIRED" are compulsory. You should only send this form if you are sure that you are eligible to join this practice. The practice website has details about our catchment area. Please note, completing this form will NOT automatically register you with the surgery. We aim to process the form within 2 working days. This should not delay treatment or care - if you need urgent treatment in the interim, please do discuss this with a member of our reception team. You will be required to present in person to sign your registration form and provide proof of your address. This process is currently delayed due to COVID and we will contact you when have restarted this. Please note, sending this form does not guarantee that you will be accepted onto the practice register. If you are not accepted onto the register we will inform you why, the most common reason is that you do not live within the Practice catchment area.

Last Updated: 12/10/2020

Personal Details


















About You













Please help us trace your previous medical records by providing the following




If you are from abroad




If you are returning from the armed forces





Carers






Next of Kin





Medical Information








Family History

Please let us know if any of your close relatives have had any of the following conditions. Please include their relationship to you and the age at which they first developed that condition.







Medication

We will automatically get details of your previous medications from your previous GP. However, we will not automatically issue these to you and would like to talk to you about your regular medications and your health conditions first. Please do therefore book an appointment with one of our GPs or pharmacists well in advance of when your medication is needed so these can be issued to you. Thank you.


Allergies



Health Information















Alcohol Consumption

As a rough guide, each of the following is 1 unit of alcohol: - Half a pint of regular strength beer, lager or cider - Half a small glass of wine - 1 single measure of spirits - 1 small glass of sherry - 1 single measure of aperitifs And each of these is more than one unit: - A pint of regular beer, lager or cider is 2 units - A pint of strong or "premium" beer, lager or cider is 3 units - A bottle of alcopop is 1.5 units - A 250ml glass of wine is 3 units - A 75cl bottle of wine is 9 units To calculate your units more accurately you may wish to go to: https://www.drinkaware.co.uk/tools/unit-and-calorie-calculator.


Patient Groups

We have a group of patients who work with members of our practice team to improve the care and services that we provide. We are keen to hear from all of our patients so that we can provide the best possible care to everybody. Things that we have worked on recently include improving the care we provide to our patients with diabetes and improving how we are able to provide services to our patients who use wheelchairs. If you express interest below, we will contact you with more information about what we are working on and how you can join the group. If you would like to give us feedback or to help us improve our services in a way but are not sure if you want to join the patient participation group, then send us an email or speak to any member of staff.


Online Access

Please read the information at on our Online Services Page - www.lhgp.org.uk/online-services. This will help you make a decision regarding whether you would online access to booking appointments, requesting repeat prescriptions or accessing your medical record. If you wish to have online access via Patient Access, please complete the following:



Data Protection and Sharing

Some Data is collected by the NHS centrally for research purposes. To opt out of ‘National Data’, please visit www.nhs.uk/your-nhs-data/manage-your-choice. In accordance with the Data Protection Act, Lavender Hill Group Practice needs consent from any patient for us to leave a message, send a text or information regarding their medical treatment. By providing information on this form you are consenting to be contacted about your medical needs by the practice. To make an informed decision about data sharing, please make sure you read our "Your Health Record" Page, https://www.lhgp.org.uk/your-health-record




Summary Care Record

Please read the information on our "Your Health Record" Page (https://www.lhgp.org.uk/your-health-record) regarding Summary Care Records before informing us of your choice below.


Declaration






FORM COMPLETION

We thank you for completing this form. We will be in touch in due course to request proof of identification. If you require any more information on the practice, please visit our website, www.lhgp.org.uk. If your details change, or you would like to change your choices regarding how we contact you or share your data, please inform us.

SUPPLEMENTARY QUESTIONS and 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.


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).















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.

Reception Only