Care Home Registration Form

 

Complete this form for a patient living in a care home to join our surgery and our Care Home Assessment Team.

You must complete one form per person. 

Last Updated: 11/04/2024

Patient's Details























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

Please Note: These questions are optional and your answers will not affect your entitlement to register or receive services from the NHS but may improve access to some NHS priority and service charities services.




IF YOU ARE FROM ABROAD

Please Note: These questions are optional and your answers will not affect your entitlement to register or receive services from the NHS but may improve access to some NHS priority and service charities services.




Armed Forces

Please Note: These questions are optional and your answers will not affect your entitlement to register or receive services from the NHS but may improve access to some NHS priority and service charities services






Nominate a Pharmacy

Our prescriptions are now signed, sent and processed electronically. Prescriptions are sent electronically to your nominated pharmacy.

You will need to nominate a pharmacy.

Use the NHS 'Find a Pharmacy' tool to choose your preferred pharmacy:

Find a pharmacy - NHS (www.nhs.uk)


HEALTH QUESTIONS

It can take time for your medical records to get to us from your previous surgery. This is why we ask you to complete our health questionnaire below. It helps us to have as much medical information about you, as possible. Particularly when treating you as a new patient.












Lifestyle Questions

For guidance on calculating alcohol units use this tool:

Interactive Alcohol Unit Calculator

















Family history

When completing this section, a 'Close Relative' means:

  • Mother
  • Father
  • Brother
  • Sister 


Immunisations

We don't always receive your immunisation history from your previous surgery. If you know your immunisation history please tell us. We can then keep your medical record as accurate as possible.

Often you can access this information via the NHS App or NHS Website Login or other online health apps such as SystmOnline, Airmid, Patient Access etc.



NHS Organ Donor

All adults in England are now considered to have agreed to be an organ donor when they die unless they have recorded a decision not to donate or are in one of the excluded groups.

If you would like to opt-out or to learn more please visit:

https://www.organdonation.nhs.uk/register-your-decision/

 

 

 

IF YOU ARE COMPLETING THIS FORM FOR SOMEONE ELSE





Our Privacy Notice, Data Sharing Policy and Options

Before completing this section, please read our Privacy Notice and Data Sharing Policy. These give you more information on:

  • The data we hold on you
  • What we do with your data
  • Who we share your data with
  • Your rights under General Data Protection Regulation (GDPR)

You can view the Privacy Notice and Data Sharing Policy on our website:

https://www.coastalmedicalpartnership.nhs.uk/see-our-privacy-notice-and-data-sharing-policy

 





CONFIRMATION

By submitting your data online via our encrypted process, you are giving us permission to register you as a patient. We only use your information to set you up as a new patient. Once your application is complete, a PDF version will be added to your notes and the form deleted from our online contact form system.




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