HANDBRIDGE MEDICAL CENTRE Greenway Street, Chester, CHA 7/5 Tel (01244) 680 169 handbri alcentre@n! et DrSusan O'Dell MBChB DRCOG Dr Catrin Clwyd Jones MBBS MRCGP DMG DRCOG Dr Charlotte Rowland BSe MBBS DRCOG DFSRH MRCGP DCH Dear New Patient, Thank you for considering registering with us at Handbridge Medical Centre. Please complete the enclosed forms, and return them to the surgery with the following personal items, these are needed before we are able to register you with us: (This is to avoid potential cases of fraud.) © Proof of Address + Proof of Identity The following forms are enclosed for your completion: ‘+ Registration Form ‘+ Pationt Health Questionnaire Patient contract to read and sien also give you the following forms for your information: Information about National Summary Shared Records ‘© Patient information Leaflet ‘© Patient Access Information Leaflet and NHS App information Please ensure that you complete the forms as fully as possible as this will allow us to process your registration promptly. As soon as you have completed the above forms and signed contacts please return to Handbridge Medical Centre, your medical records will then be requested from your Previous GP Surgery and transferred to us in the coming weeks. Please read the information about the National Summary Shared Records carefully and let us know if you would like to opt out. Please note that if you opted out at your previous practice you will still ced to fill in the opt out form to ensure your wishes are carried over to our practice records. | would like to take this opportunity, on behalf of all the tearm, to welcome you to the Handbridge Medical Centre. Yours sinceraly ‘The Handbridge Medical CentreHandbridge Medical Centre Patient Contract Dear Patient ‘As you have applied to join our practice we would like to inform you of our practice policies. We advise you to read the following closely and document your agreement with this patient contract with your signature (a copy of which will be kept on your record). Should you not wish to agree to our surgery policies we will not be able to register you as a patient at this practice. Violence & aggression ‘We operate a zero tolerance policy towards violence and aggression. Any patient who behaves in a manner that could be classed as violent or aggressive towards a member of our staff or another patient, on or off surgery premises, will be instantly removed from our patient list and may be repurted tw the police, Repeat Prescriptions Repeat prescriptions can be ordered by completing the repeat medication slip attached to your prescription and either hand ar past into the surgery. Repeat prascriptions can also be ordered online using the Patient Access service. Further details on how to register for this service are contained within your patient registration pack. Your prescription will be ready for collection 2 working days from receipt by the surgery (as outlined in our Practice Leaflet). It is your responsibility to ensure that you order sufficient medic holiday periods. Medication not prescribed The practice has a strict prescribing policy, and there are a number of items which the practice does not prescribe which you should be aware of before registering. Items not prescribed: «Hayfever medication (only in exceptional circumstances) ‘* Sunscreen (only in exception circumstances) * Zopiclone © Diazepam + Temacepam * Gluten Free Products * Over the counter medications requested for short term acute illnesses, such as Paracetamol, Ibuprofen. in for your needs, particularly during Appointments ‘Appointments can be booked by telephone, in person or online (Patient Access Service). As we are a very busy surgery we are not always able to offer routine appointments at sliort notive, Should you suffer a genuine medical emergency we may be able to offer a telephone appointment with Duty Doctor however, these appointments are reserved for genuine medical emergencies requiring immediate medical attention and cannot be used for reasons of convenience. Home visits We are only able to offer home visits in exceptional circumstances, such as when a patient is genuinely housebound, ‘or where 2 medical problem makes it impossible for a patient to be brought to the surgery. Lack of transport attend at the surgery is not a sufficient reason to request a home visit. Fail to attend The practice operates a strict policy for patients who fail to attend their appointments. Patients who persistently fail to attend may be removed from the practice list. Consent Do we have your consent to send out text messages/emalls to remind you of your appointments? Please confirm if you give your consent to do this. YES Igive consent NO-I do not consent Print Name: Dor bof mm _syyvy Signed: Date: 0D MM _Jvyvy‘As an NHS surgery, of course all the information we hold about you is kept strictly private and confidential and subject to the Data Protection Act. However, itis possible for us to share some of your information to other NHS care providers, should you allow us to do so. It is our GP’s recommendation to consent to both a Cheshire Care Record and a detailed Summary Care Record, as these choices will grant you the best medical care possible throughout the NHS, but itis entirely your choice. Please read both sides of this sheet and return the form below, filling in both sides. There are two separate ways you can chose to share your records. 1) Sharing your Local Care Record, to NHS trusts, locally, allowing better access for local NHS services. 2) Sharing your Summary Care Record, to NHS trusts, Nationwide for emergency care. For more information please see below. " Cheshire 1). Sharing your Local Care Record, to NHS trusts, locally. Care Record There are a number of local NHS services open to our patients, including, Accident and Emergency (COCH), Out of Hours, Extended Hours, Physio First, District Nurses, Mental Health Teams, Midwives, Health Visitors, Community Physicians, Occupational Therapists, Community Matrons and Outpatients Departments (COCH). In order for these services to be able to offer you the best care, it is usetul it they can see your medical record and it is recommended by our GP's to opt in. Frequently asked questions Can all medical professionals across Cheshire access my medical notes? * No. Only those professionals who are directly involved in your care/treating you Will my details be sold onto third parties? x No. Never. Will my medical notes be shared outside of the NHS and social services? * No. Never. If | consent to sharing will local NHS professionals | see outside of Handbridge Medical Centre have access to my notes should | seek treatment/care from them? v Yes. If consent will | still have | explaii * Less often. ‘Will consent for local sharing allow my personal information to be shared with the Governments Care Data programme to help intorm national healthcare planning? * No, my medical story over and over again? For more information please visit www.cheshirepioneer.co.uk/chesire-care-record e Care Record Opt In/Out Form for Cheshire Care Record (Local Services). 1 Yes | would like a Cheshire Care Record — allowing local health professionals caring for me access to my medial notes. (Recommended) (No | would like to decline consent for a Cheshire Care Record | do not want local health professionals caring for me to have access to my medical notes. Print Name:_ Dos: Sign Name: Date Signed:2) Sharing your Summary Care Record, to NHS trusts, Nationwide. Your Summary Care record can be used in emergency care, if you opt to allow this our local hospital, the Countess of Chester, and any national NHS trust hospital will have access to information regarding any medications you are taking, any allergies you have, or any reactions to medications that are known to us Although we all hope we will never need emergency care, or be unfit to inform your care givers of the information they need, should this happen you can rest assured your caregivers have access to your basic information in order to give you the best care, allowing this information to be shared nationally is recommended, as for example if yau were to become ill outside of our local area, perhaps visiting a friend, or family, or travelling with work, the staff at the hospital close to where you are would still have the information they need to offer you the best care. Should you wish to, you can also opt to allow the NHS trusts access to more detailed information, this would include; significant medical history (past and present), reasons for medication you are on, anticipatory care information (e.g info. about the management of long term conditions), end of life care information, immunisations. Again in order to receive the best care, our GP’s recommend this option, When a patient registers with our surgery we ask them if they would like a Summary Care Record, for existing Patients it Is different in that as they registered before the Summary Care Record system was created, by default they were opted in, in order to allow them the best care, unless they actively decided to opt out. Patients can change their mind and chose to opt in or out at any time. Frequently asked questions Can all medical professionals Nationwide access my medical notes? * No. Only those professionals who are directly involved in your care/treating you Will my deteils be sold onto third parties? No. Never. Will my medical notes be shared outside of the NHS and social services? * No. Never. If consent to sharing will NHS professionals Nationwide outside of Handbridge Medical Centre have access to my notes should I seek treatment/care from them? v Yes. If [consent will | still have | explain my medical history over and over again? * Less often. Will consent for local sharing allow my personal information to be shared with the Governments Care Data programme to help inform national healthcare planning? * No. For more information please visit www.nhscarerecords.nhs.uk 2 Opt In/Out Form for Summary Care Record (National services). Yes | would like a Summary Care Record - allowing access to my basic information D Yes | would like a Summary Care Record — allowing access to my more detailed information. (Recommended) BNo | do not want a Summary Care Record. Print Name: Dos: Sign Nami Date Signed:Patient Health Questionnaire Thank you for registering with Handbridge Medical Centre. Unfortunately it may be some time before your previous records arrive at this practice. We would therefore be grateful if you could answer the following questions. This will give us a better idea about your health, and help us to look after you. Please circle the relevant answer throughout the questionnaire. Date of registration: ..... Address: ......csve Telephone number . Mobile Number Occupation: Email . Country of ar Fthnicity: Next of Ki Next of kin (Name): : es Next of kin telephone number: Next of kin addres Can this next of kin have access to your medical records? Is there anything you do not want you next of kin to discuss?. Carers Do you care for a vulnerable person (adult or child) Yes No If Yes, please ask our Carers Lead (Evelyn) for a carers pack that has helpful support and information. Do you have a carer/social worker/warden? Yes No Accessible Information: Do you need help with mobility/hearing/speaking or your vision? (Tick all that apply) Wheelchair Walking aid Struggle to use stairs | Hearing Aid British Sign Language | Makaton sign Lip Reading Difficulty with sight Language when reading Hearing when using | Any visual Other Other. a telephone impairment Do you require an interpreter? Yes No If yes, which language?....... Medical History Do you suffer or have suffered from any of the following conditions, if yes since when? Condition Heart Disease Yes No Since: Stroke Yes No Since: Cancer Yes No Since: Diabetes Yes No Since: Asthma, Yes No Since: High blood pressure Yes No Since: Yes No Since:Yes Pleasc list any other serious illness, operations or accidents you had in the past (give dates when possible) Please list any medicines/tablets you are currently taking: Do you have any allergies? Yes Please list. What is your Height. Lifestyl Smoking status Never smoked Ex-smoker Current Smoker: If current smoker: year when you started: If ex-smoker: Year when you stopped: ‘Average cigarettes per day: What regular exercise do you take? Family Medical History las a member of your immediate family (father, mother, siblings, and grandparents) had or suffered from any of the following? If ‘Ves’, Please state relationship and condition. Condition Relationship Heart attack Stroke Cancer jabetes hh blood pressure Other. Chiamy screening Would you like to do this test? Yes No If yes please collect a pack from the restroom and hand it in at reception. Would you like to speak tothe nurse? —Yes No Female patients only Have you ever had a cervical smear? Yes No IfYes When? What was the Result? ..Advised Recall time? ........ssssscessssseeesseeeeee 7 Are you using any contraception? Yes IF Yes what method? Alcohol Screening Questionnaire Do you drink alcohol? Yes No How many units a week? .. (Wine: 125ml glass = 1.5 units, 175ml glass = 2.0 units: 250ml glass = 3units. pint of lower strength lager/beer/cider = 2 units: pint of higher strength lager/beer/cider = 3 units; single small shot of spiri unit) Please circle the most relevant box for each question. ‘Alcohol Screening Questions 1. How often do vou have a drink containing 24 5. 4 alcohol? Never | Monthly orless | Times a month Or more times a week 1 2 | 4 | 2 How many drinks containing alcohol do you have on a typical day when you are drinking? 3. How often do you have 6 or more drinks on | Lessthan fone occasion? monthly as a relative of friend or a doctor or other health worker been concerned Nu Yes, but novin ‘Yes during the about your drinking or the past year last year suggested you cut down? you would like further information or have any questions around alcohol use please ask to speak to a Doctor or Nurse. If you would like to calculate how many units of alcohol you have per week please go to http://units.nhs.uk