Confirmation of Registration Welcome to Kimbolton Medical Centre To complete your Registration with us, please fill in this form, ensuring that you complete all required fields. This form can take up to 10 minutes to complete. If you would like any help with completing this form please visit the surgery. Paper versions of these registration documents are available on request. Registrations may take up to 5 days to be processed.Please Choose one of the following options:I am an existing Kimbolton Medical Centre patientI have registered as a New Patient at Kimbolton Medical Centre in the last 5 days.Your Title Mr Mrs Miss Ms Other Name First name / names Surname Date of Birth MM slash DD slash YYYY NHS Number (if known) OptionalFind your NHS numberAddress Street Address Postcode The First line of your address and postcode Main Contact Telephone NumberAlternative Contact Telephone Number OptionalEmail Address Optional By supplying an email address you are consenting in allowing us to email you with relevant NHS healthcare services.Preferred Method of ContactMain Contact Telephone NumberAlternative Contact Telephone NumberEmail AddressPlease provide a mobile telephone number wherever possible. By doing so, you will be automatically enrolled to our text reminder service. All telephone numbers MUST be registered in the UK. We will use this information for: contacting you about your health when unable to contact you at home / texting your appointment reminders / responding to your queries / advising when your prescriptions/paperwork is ready / advising you if appointments are cancelled.Confirmation Medical QuestionsThese questions are not asked on our previous form, but are important in helping us to tailor your individual Care needs. 1. Have you or any of your close relatives suffered from any of the following? Heart Attack Diabetes High Blood Pressure Asthma Stroke Cancer (please specify which type) Any other Serious Illnesses (please describe) If so please click on any that apply and give details in the box below. If more than One apply please give details for all.Please give further detailsfor example, what relation and the age for your reaation when diagnosed.2. Have you suffered from any Major Illnesses or had any Major Operations that we should be aware of? Yes No Please supply details3. What is your current Job role?This allows us an insight into potential risks at your place of work, helping us narrow down any potential diagnosis if ever required.4. Do you currently Smoke or Vape? Yes No Would you like to be referred to a Smoking Cessation Clinic? Yes No This could help you reduce or even quit Smoking to help improve your health.5. Are you a Carer or do you have a Carer help you? Yes No Would you like us to put you in contact with a Care Co-Ordinator, who can put you in contact with local support groups and sevices that may help you? Yes No They can help you with their local knowledge of groups / services available.6. What is your first Language ?(i.e the language you use at home). This will help us provide you with better information and allow us (when possible) to send you information in your home language.7. What is your Religion ?Knowing this will help us take into account any potential religious factors that may affect your care.Verifying your IDTo help us to verify your ID, please choose 3 of these questions. (Please ensure they are 3 different questions, answering the the same question in all 3 boxes will void the form)Question 1When did you last see your Doctor or Nurse?When did you last speak to your Doctor or Nurse on the Telephone?Do you take any Regularly prescribed Medication?Have you had any Operations, and if so at which Hospital?What year did you join Kimbolton Medical Centre?Do you have an Hearing aid?When did you last order your Medication?Do you have any Allergies?Do you have any long term conditions, eg Asthma or Diabetes?Do you have a Keysafe number? (if so, please just answer yes or no in the Answer box, DO NOT enter your Box Number)Answer 1Question 2When did you last speak to your Doctor or Nurse on the Telephone?What year did you join Kimbolton Medical Centre?Have you had any Operations, and if so at which Hospital?When did you last see your Doctor or Nurse?Do you have an Hearing aid?When did you last order your Medication?Do you take any Regularly prescribed Medication?Do you have any Allergies?Do you have any long term conditions, eg Asthma or Diabetes?Do you have a Keysafe number? (if so, please just answer yes or no in the Answer box, DO NOT enter your Box Number)Answer 2Question 3Do you have any Allergies?Do you take any Regularly prescribed Medication?Do you have any long term conditions, eg Asthma or Diabetes?When did you last speak to your Doctor or Nurse on the Telephone?Do you have an Hearing aid?Have you had any Operations, and if so at which Hospital?When did you last order your Medication?What year did you join Kimbolton Medical Centre?When did you last see your Doctor or Nurse?Do you have a Keysafe number? (if so, please just answer yes or no in the Answer box, DO NOT enter your Box Number)Answer 3Online AccessYou can now use the internet to manage appointments, request repeat prescriptions for any medications you take regularly, check test results and look at your medical record online. Being able to see your record online helps you to manage your medical conditions. It also means that you can access it from anywhere in the world should you require medical treatment on holiday. The service is open 24hrs a day / 7 days a week / 365 days a year and can be accessed from your home PC, Tablet or Mobile phone You have the option to opt out of this service at any time by contacting the practice. Click here for more information about using / downloading the NHS AppSummary Care RecordThere are strict laws and regulations to ensure that your health records are kept confidential and can only be accessed by health professionals directly involved in your care. There is some sharing of information as detailed below. You can opt out of any of these at any time if you wish. NHS Summary Care Record (SCR) – this is an electronic record which contains information about the medicines you take, allergies you suffer from and any bad reactions to medicines you have had. Having this information stored in one place makes it easier for healthcare staff to treat you in an emergency, or when your GP practice is closed. If you need more time to make your choice you should let your GP Practice know. For more information talk to the Patient Experience Team on 0800 2792535, email CAPCCG.pet@nhs.net or visit the Cambridgeshire & Peterborough Integrated Care System website,. You can also telephone the dedicated NHS Summary Care Record Information Line on 0300 123 3020, , visit their website, or contact your GP practice staff. You can choose not to have a Summary Care Record and you can change your mind at any time by informing staff at Kimbolton Medical Centre. If you do nothing we will assume that you are happy with these changes and create a Summary Care Record for you. If you would like further details on how to Opt Out and what this choice means, please visit the NHS Your Data Matters website.I agree to opt in or opt outI agree to OPT – INI DO NOT agree to OPT – INYour Health Record and Sharing of InformationSharing Out – This controls whether your information recorded at this Practice can be shared with other healthcare professionals. Sharing In – This determines whether or not this Practice can view information in your record that has been entered by other services who are providing care for you or who may provide care for you in the future. Please indicate your choices about sharing your health record. Sharing Out Yes No I would like my health record at this Practice to be shared with other healthcare services providing care for meSharing In Yes No I would like this practice to be able to view information in my health record that has been recorded by other health care servicesYour DataYour Data I certify that the information I have provided is correct and consent to my personal and medical information being used as stated above.What happens to my information? Personal and medical information about patients registered at this practice are primarily kept electronically, although some is kept in paper form. Some information will be sent to hospital consultants and other health professionals to whom you are referred by your GP in order to provide continued healthcare and obtain treatment for you. We sometimes use accredited suppliers for our communication with you, for example when we send recall letters for review clinics or medication reviews. All suppliers we use are checked carefully to ensure they comply with strict confidentiality protocols To ensure the security of all patient information, all staff that has access to your records is covered by confidentiality clauses in their contracts and the Data Protection Act and the Freedom of Information Act. Our guiding principle is that we hold your records in strict confidence.
