Vine Medical Group Patient Registration Form

In order for us to offer you the high standards of clinical care we give to our patients, we ask that you complete this online form. If you require help, please inform reception so that assistance can be arranged.

Previously Registered

Have you previously been registered at any of the following GP practices?

Personal Details
Title required.
First name required.
Surname required.
Day of birth required.
Month of birth required.
Year of birth required.

Gender

Gender required.
Country of birth required.
Required

Ethnicity

Home Address Details
Number and street required.
Town required.
County required.
Postcode required.
Current Contact Details
Previous Address & Doctor Details

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

If you are from abroad

If previously resident in the UK, date of leaving

Date you first came to live in the UK

We cannot process your registration without this information

Veterans

A veteran is anyone who has served for at least one day in the armed forces, whether regular or reserve. This also applies to Merchant Navy seafarers and fishermen who have served in a vessel when it was being used for military operations by the armed forces.

Are you a veteran?

Required.

Are you a family member of a veteran?

Required.

Are you dependent of a veteran? (A ‘dependent’ is a person who relies on another for financial support.)

Required.
If you are returning from the Armed Forces

If you are returning from the Armed Forces, we require a copy of your ‘F Med133 Discharge Form’ in order to process your registration. You cannot be registered permanently without this.

Enlistment date

Discharge date

Next of Kin

Emergency contact

Can discuss record (This relates to discussing your medical record in an event of an emergency, if required. Note, this does NOT include routine sharing of information. If you would like a nominated person to have permission to discuss your medical record with us, please supply a separate letter of consent.)

If you have a carer

Do you require a carer for some or all of the time?

Required.
If you are a carer

Are you a carer for someone for some or all of the time?

Required.

Is this person a patient at Vine Medical Group?

Employment

Are you employed by a care home?

Required.

Are you employed by a nursing home?

Required.

Are you employed by a domiciliary care provider?

Required.
Care and Health Information Exchange (CHIE)

The Care and Health Information Exchange (CHIE) is a secure system which shares health and social care information from GP surgeries, hospitals, community and mental health, social services and others.

Required.
Summary Care Record (SCR)

The Summary Care Record is a national scheme and is used to support your emergency care. The information will be very limited, and may include medication, allergies and adverse drug reactions. Patient consent will be required each time by anyone accessing the medical records (unless they are unconscious).

Required.
Consent

To ensure you receive the right care we may share information about you and your care with other health professionals. We will only use or pass on identifiable information about you with other health professionals who are involved in the direct provision of your care. They will ask your permission to view your information when they first see you. We will not disclose your identifiable information to anyone else without your permission unless in exceptional circumstances (i.e. life or death situations), or where the law requires it. The NHS currently uses your information in an anonymous and safe way to:

  • protect the health of the public
  • help us anticipate, plan and provide care
  • audit and monitor the quality of services provided
By registering with this practice you are consenting to your information being shared. However, you can ask for your information not to be shared outside of the practice. If you decide to opt out it will not affect your entitlement to care. However, it may result in the delivery of your care being less efficient as clinicians will not see your full medical history. If you have any concerns about how your information is shared or held, please contact the Practice Manager.

Required.
Communicating with you

Do you give permission for us to leave non-urgent messages on your answerphone?

Required.

Vine Medical Group is run, and on the services offered. This is known as the Virtual Patient Participation Group (VPPG). We will not share your details with any third party and your feedback is valuable in ensuring we offer you the best possible service. We may also send you emails regarding new services or information regarding Vine Medical Group, such as flu clinics. If you would not like to participate, please tick this box.

If you have provided your mobile telephone number, we can send you SMS text messages to remind you of upcoming appointments, as well as useful information such as flu vaccination clinics. If you would not like to receive these messages, please tick this box.

Smoking Status & History

Do you smoke?

Required.

If you DO smoke, are you aged 35 or older?

Alcohol (AUDIT-C)

Required.
Required.
Required.
Conditions

Do you have any of the following conditions?

Allergies

Do you have any allergies?

Required.
Family Member Conditions

Do any of your family members have a history of, or problems with:


If yes to IHD, was or is the family member...

EPS & Repeat Dispensing

Vine Medical Group are encouraging all patients to use EPS and Repeat Dispensing to maximise the safety, efficiency and time saving features it offers.

What is EPS?

EPS is the acronym for ‘Electronic Prescription Service’, the NHS service that enables your prescriptions to be sent electronically (excluding controlled drugs) to the pharmacy or chemist of your choice. EPS allows you to request medication directly from your pharmacy, meaning you will no longer have to collect a paper repeat prescription from Vine Medical Group, and can instead collect your medicines from your pharmacy or chemist.

Because your pharmacist has already received your electronic prescription before you arrive, they may be able to prepare your items in advance so you can collect with no extra wait.

All new patients MUST select a pharmacy for EPS by completing the following:

If you do not choose a pharmacy, one will be allocated to you based on your location. Read on for more information about EPS.

Required.
Patient Participation Groups

At Vine Medical Group we believe passionately about receiving and acting on constructive feedback from patients. As a result, we have two patient groups, known as the ‘Virtual Patient Participation Group’ (VPPG) and the ‘Patient Participation Group’ (PPG), both of which enable you to have a voice in the way we run the practice.

Virtual Patient Participation Group (VPPG)

All contact is by email. We will email a link to a survey one or two times a year. You will be asked a series of simple questions about how we are doing. Our aim is to reach out to a wide range of patients from across our population, and as such by submitting your email address during registration you will be automatically added to the VPPG. If at any time you wish to be excluded, simply reply to any of the emails stating that you do not wish to be included.

Patient Participation Group (PPG)

Currently, this is a group of patients helping us create a connection between the practice and the patients. As a member of our PPG, you could influence the decisions taken within the practice about the services we offer. We hold quartely face-to-face meetings to discuss government agendas and their impact on our services, as well as the current priorities for Vine Medical Group. You will have an opportunity to ask non-personal questions and provide a voice from the patient perspective.

Would you like to be contacted regarding joining the Patient Participation Group?

Required.
Accessible Information

Do you have any communication or information needs that we should be aware of?

Required.

Do you give consent for this information to be shared with other healthcare organisations as and when required?

Useful Information

Have you visited the Vine Medical Group website at www.vinemedicalgroup.co.uk?

Required.

Have you visited the Vine Medical Group Facebook page?

Required.

Association(s) with Vine Medical Group

To the best of your knowledge, are any of your relatives or friends currently employed by Vine Medical Group?

Required.

Patient Declaration
How We Use Your Data

A new privacy law will be introduced in the UK in May 2018 called the General Data Protection Regulations (GDPR 2018). The law requires the Practice as the ‘data controller’ to process the data we hold about our patients and staff ‘fairly, lawfully and transparently’, to collect data for ‘specified, explicit and legitimate purposes’ ensuring that the data we process is ‘adequate, relevant, limited to what is necessary, accurate and up to date’.

As a result, we have published a new Privacy Notice to make it easier for you to find out how the Practice uses and protects patient and staff data. A copy of the Privacy Notice for patients can be found on our website at http://www.vinemedicalgroup.co.uk/privacy-notice.

By submitting this application, you are declaring that the information completed is accurate to the best of your knowledge.

Any suspected fraudulent information will be reported to the relevant authorities.

Today’s date: Saturday 21st September 2019

Required

I am...

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