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New Patient Questionnaire

New Patient Questionnaire

(By giving us this information you are happy for us to email information to you relating to your care)

Next Of Kin details:
Prescriptions: – to be ordered online

Prescriptions are sent electronically to your nominated pharmacy

Carer Status

Please let us know if you are the main person responsible for looking after and caring for someone who is dependent upon you

If yes, please provide the following details for your Carer:

Children Under 12

If Yes please could you provide us with their details:

Ethnic Origin

In accordance with new Public Health requirements we require the following information.

Communication Needs
Your Health

Smoking Information

Alcohol Intake Information:

If Yes please could you provide us with your repeat prescription ‘tick list’ from your previous surgery, if you have one.

Have you ever had any of the following?

Online Services

For anyone aged 16 and over we offer online services for appointment booking and repeat prescription ordering. This is the quickest & easiest way to order your medication. We will need to see 2 forms of ID to be able to register you for online services, preferably 1 photo and 1 with proof of your current address (within 3 months). Once registered, you will also be able to view your summary record, detailing current medication, allergies and vaccinations

(If you decide not to use online services you will need to bring your prescription request in to the surgery as we are unable to accept either telephone or pharmacy requests)

These are confidential: It is your responsibility to ensure they can be received securely by text or email. Please note that photographic ID will be needed if collecting a printout. You will also be provided with details for registering with the approved ‘Systmonline App’ if you wish to use it.

For children under 11 years:

An adult with parental responsibility can nominate themselves to have access to their child’s online services. Once a child reaches 11, access is automatically removed. Please provide details below of the adult requiring access:

Proxy access:

If you are aged 16 or over you can nominate another person (called a ‘proxy’) to have access to your online Services (this is called proxy access). This will allow the nominated person to access your on-line account to book appointments and order prescriptions. You can choose to end this access at any time after it has been granted. ID checks would need to be done on the nominated proxy. If you would like to nominate a person to have proxy access, please ask at reception for an application form.

Access to your medical records

If you would like online access to your medical record you can apply for this by requesting an application form from reception or by downloading one from the practice website. This access is subject to an authorisation process and can take up to 20 working days to complete once your application has been received. You will need to provide 2 forms of ID (including 1 photographic) on application, which needs to be done in person. For further information on GP online services go to:

Your Medical Information – Sharing Your Data:

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. More information is available on the website or the number below. Please see the Privacy Notice on our website for more information on how your data is held and used by the practice.

Enhanced Data Sharing: ( We would like to make your whole medical record AVAILABLE to other authorised healthcare staff, involved in your care (eg the District Nurse). They will not see your record unless you GIVE them your permission to see it.

Enhanced Data Sharing: Park Parade Surgery would like to see your whole medical record, including information created by other authorised healthcare staff involved in your care.

Summary Care Record: ( This record will contain summary information about any medicines you are taking, allergies you suffer from and any bad reactions to medicines you have had to ensure those caring for you have enough information to treat you safely.

Your Summary Care Record will be available to authorised healthcare staff providing you with care anywhere in England, but they will ask your permission before they look at it. This means that if you have an accident or become ill away from home, healthcare staff treating you will have immediate access to important information about your health.

Your Data Matters: ( Tel: 0300 303 5678)

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 safe and will always be clear on how it is used. You can choose whether or not your confidential patient information is used for research and planning. If you do not wish your information to be used in this way please opt-out by visiting the website or calling 0300 303 5678. The practice is unable to record this for you.

Privacy Protection

Information submitted through secure forms is used only for the purposes of processing your request. We may be in touch with you in relation to the information submitted.

All Information submitted through secure forms is secured with a private key and is accessed over a secure connection by nominated staff. We have a strict confidentiality policy.

This information is not shared with any third party organisations.

This information is retained for up to 28 days.

Learn more about our Privacy Policy and Terms of Use. Should you have any concerns about sending your personal details using the web, please use one of the alternative methods offered by our organisation.

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