Confirmation of Registration - old - Kimbolton Medical Centre

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:

Your Title

Mrs

Miss

Other

Name

First name / names Surname

Date of Birth

MM slash DD slash YYYY

NHS Number (if known) Optional

Find your NHS number

Address

Street Address Postcode

The First line of your address and postcode

Main Contact Telephone Number

Alternative Contact Telephone Number Optional

Email Address Optional

By supplying an email address you are consenting in allowing us to email you with relevant NHS healthcare services.

Preferred Method of Contact

Please 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 Questions

These 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 details

for 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

Please supply details

3. 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

Would you like to be referred to a Smoking Cessation Clinic?

Yes

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

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

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 ID

To 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 1

Answer 1

Question 2

Answer 2

Question 3

Answer 3

Online Access

You 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.

Your 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.

Online Information Sharing Form (Required)

We use a secure electronic health records system called SystmOne. With your permission, this system can allow clinicians to share your full record held here with other healthcare services who are providing care for you. These other services will ask your permission to view your record.

Many organisations use SystmOne including some GP practices, out of hours services, children’s services, community services and some hospitals. Sharing your health record will help us deliver the best level of care for you.

You have two choices which allow you to control how your record is shared. You can change these choices at any time by letting the relevant Practice or Service know.

Online Information Sharing Form