Patient Registration Form

To register with the practice, please complete questionnaire in full or this will affect your registration.

Please complete the following where possible:

Are there any of the following in your family (father, mother, brother, sister)

who have had any of the following conditions before the age of 65?

An allergy is where your body reacts to something that is normally harmless like certain foods, pollen, dust or animal fur. The symptons can be mild, but for some people they can be very serious.

A food intolerance is when you have difficulty digesting certain foods or ingredients in food. It is not usually serious, but eating the food your are intolerant to can make you feel unwell.

Name and address of the pharmacy you would like us to send your prescriptions to.

THE BELOW MUST BE COMPLETED OTHERWISE THIS COULD AFFECT YOUR REGISRATION

This allows you to book appointments, request prescriptions etc.

If you wish to have have access you will be responsible for the security of the information that you see or downlaod.

If you choose to share your information with anyone else, this is at your own risk.

You will contact the practice as soon as possible if you suspect that your account has been accessed by someone without your agreement.

If you see information in your record that is not about you or is inaccurate, you will contact the practice as soon as possible.

The practice wishes to expand its methods of communicating with patients to include the use of email and text messaging.

Due to the fact that we are not always notified about a change of phone number, our first method of contact will always be email, this is also a more secure method for the patient and the practice.

Patient Privacy is important to us, and Petersfield Surgery would like to communicate with you regarding any activities that may be of interest, which means that we need your consent.

Emails and text messages are generated using a secure facility, but because they are transmitted over a public network they may not be secure. Email and text communication will never be used for urgent communications. Your contact details will be used solely in relation to healthcare services offered by the practice, and you can choose to opt out of the services at any time by contacting the Reception staff. You can grant consent to all the purposes of use, one of them or none of them.

Where a patient does not grant consent then the Practice will not be able to use your personal data.

Please complete the below.

LETTERS AND CORRESPONDENCE FROM THE PRACTICE: WE ARE ALWAYS KEEN TO SUPPORT OUR PATIENTS IN ANY WAY.

Solicitors letters / Letters for court / Employment letters CANNOT be requested by the patient. These requests have to  be formally requested by the third party and must be supported by that patients signed consent.

Email, telephone or verbal requests will NOT be accepted.

A minimum of 7 days notice should be given to allow time for records to be checked.

Prescriptions issued by hospitals/psychiatrists are generally intended for short term use only. The patient must be under supervision of the specialist whilst on the medication.

ANTIBIOTICS Antibiotics resistance is a real threat to society. It is increasing year on year and when all the bugs are resistant we will no longer be able to offer procedures such as hip replacment, transplants and cancer treatment.

It is therefore very important that we do not use these drugs for self limiting straightforward conditions. Please be preapred to bear with a doctor if he/she does not wish to precscribe antibiotics.

SLEEPING TABLETS AND TRANQUILISERS (e.g. Diazepam, Zopiclone, Temazepam, Lorazepam, Buspirone and other similar medication)

These drugs are not licensed for long term use and the policy of the practice is not to prescribe sleeping medication at all, other than for patients in terminal care.

ANALGESICS (e.g. Codeine, Dihydrocodeine, Tramadol)

In America prescribing opoid medication kills more patients than road traffic accidents. Evidence is clear that they do not work beyond a three month period and are not used in centres of excellence, such as St Thomas's pain clinic.

We have a strict policy of trying to withdraw patients on long term opioids from treatment.

Tramadol is not a controlled drug with restrictions on long term prescribing.

We try to help and encourage our patients to seek alternative medication.

Unit guide:

1 unit is typically

Half-pint of regular beer, lager or cider: 1 small glass of low ABV wine (9%): 1 single measure of spirits (25ml)

The following drinks have more than one unit;

A pint of regular beer, lager, or cider, a pint of strong/premium beer, lager or cider, 440ml regular can cider/lager, 440ml 'super' lager 250ml glass of wine (12%)

A score of less than 5 indicates lower risk drinking please see below: A score of 5+ requires the following 7 questions

Please tick the box below as a signiture to confirm that you read, understood and agree to all above including our polices.

You also agree that all the details you have provided are all correct to your knowledge at the time of filling this form out.

0-7 Lower risk = No intervention required

8-15 Increasing risk = Brief advice

16-19 Higher risk = Brief advice and/or extended Brief advice

20+ Possible dependance = Referral to services