NEW PATIENT APPLICATION

APPLICATION FOR GENERAL MEDICAL SERVICES WITH THE UNIVERSITY OF SUSSEX HEALTH CENTRE

Correct contact details are essential in case we need to contact you via Email, Phone or Letter, regarding your medical care.

Supplying this information gives consent for us to contact you where medically necessary.

Please ensure all information is filled in as accurately as possible - missing or inaccurate information could delay your registration.

* denotes required

Personal Information

Previous NHS Details

Have you previously been registered under the National Health Service (NHS)?

Have you previously been registered under the National Health Service (NHS)? *

Last Doctor Details

Have you ever registered at this practice before?

Have you ever registered at this practice before?

Course Details

Are you a student?

Are you a student? *

University course?

University course?

Nationality and Ethnicity

Medical details

Approx. Dates of Pre-University Vaccinations:

Medical History:

Are you currently taking any medication?

Are you currently taking any medication?

Accessibility:

Smoking

Do you smoke?

Do you smoke?

Fast Alcohol Screening Test (FAST)

Unit definition: 1 Glass of Wine = 1.5 Units, 1 Bottle = 10 Units, 1 Pint of Beer = 3 Units, 1 Spirit Measure = 1 Unit

Do you have two or more alcohol free days per week?

Do you have two or more alcohol free days per week?

AUDIT - C: First 3 Questions

Enter the number (0 to 4) that corresponds to your answer in each box.

Scoring System

0

1

4

How often do you have a drink containing alcohol?

Never

Never (0 points)

Monthly
or less

Monthly or less (1 point)

2-4 times per month

2-4 times per month (2 points)

2-3 times per week

2-3 times per week (3 points)

4+ times per week

4+ times per week (4 points)

How many units of alcohol do you drink on a typical day when you are drinking?

1 - 2

1 - 2 (0 points)

3 - 4

3 - 4 (1 point)

5-6

5-6 (2 points)

7-9

7-9 (3 points)

10+

10+ (4 points)

How often have you had 6 or more units if female, or 8 or more if male, on a single occasion in the last year?

Never

Never (0 points)

Less than monthly

Less than monthly (1 point)

Monthly

Monthly (2 points)

Weekly

Weekly (3 points)

Daily or almost daily

Daily or almost daily (4 points)

Full AUDIT: Remaining 7 Questions

Only complete Full Audit if your TOTAL score above is greater than 5

Enter the number (0 to 4) that corresponds to your answer in each box.

Scoring System

0

1

4

How often during the last year have you found that you were not able to stop drinking once you had started?

Never

Never (0 points)

Less than monthly

Less than monthly (1 point)

Monthly

Monthly (2 points)

Weekly

Weekly (3 points)

Daily or almost daily

Daily or almost daily (4 points)

How often during the last year have you failed to do what was normally expected from you because of your drinking?

Never

Never (0 points)

Less than monthly

Less than monthly (1 point)

Monthly

Monthly (2 points)

Weekly

Weekly (3 points)

Daily or almost daily

Daily or almost daily (4 points)

How often during the last year have you needed an alcoholic drink in the morning to get yourself going after a heavy drinking session?

Never

Never (0 points)

Less than monthly

Less than monthly (1 point)

Monthly

Monthly (2 points)

Weekly

Weekly (3 points)

Daily or almost daily

Daily or almost daily (4 points)

How often during the last year have you had a feeling of guilt or remorse after drinking?

Never

Never (0 points)

Less than monthly

Less than monthly (1 point)

Monthly

Monthly (2 points)

Weekly

Weekly (3 points)

Daily or almost daily

Daily or almost daily (4 points)

How often during the last year have you been unable to remember what happened the night before because you had been drinking?

Never

Never (0 points)

Less than monthly

Less than monthly (1 point)

Monthly

Monthly (2 points)

Weekly

Weekly (3 points)

Daily or almost daily

Daily or almost daily (4 points)

Have you or somebody else been injured as a result of your drinking?

No

No (0 points)

Yes, but not in the last year

Yes, but not in the last year (2 points)

Yes, during the last year

Yes, during the last year (4 points)

Has a relative or friend, doctor or other health worker been concerned about your drinking or suggested that you cut down?

Never

Never (0 points)

Yes, but not in the last year

Yes, but not in the last year (2 points)

Yes, during the last year

Yes, during the last year (4 points)

Electronic Prescriptions (EPS)s

If you are on repeat medication and would like this sent direct to a pharmacy of your choosing when requesting it, you can sign up by going into your chosen pharmacy and asking them to sign up for the 'EPS Service'.

Alternatively you can ask us here, at Reception in the Health Centre.

Summary Care Record (SCR)

For more information about the SCR, please click on the links below:

About the Summary Care Record
Summary Care Record Opt-out Form

Other

In order to comply with the Equality Act 2010, GP practices are now required to request the following information. This is in order to ensure we do our best to plan our services around the diverse needs of register patients.

Supplementary Questions (Optional)

PATIENT DECLARATION for all patients who are not ordinarily resident in the UK

Anybody in England can register with a GP practice and receive free medical care from that practice. However, if you are not 'ordinarily resident' in the UK you may have to pay for NHS treatment outside of the GP practice. Being ordinarily resident broadly means living lawfully in the UK on a properly settled basis for the time being. In most cases, nationals of countries outside the European Economic Area must also have the status of 'indefinite leave to remain' in the UK. 

Some services, such as diagnostic tests of suspected infectious diseases and any treatment of those diseases are free of charge to all people, while some groups who are not ordinarily resident here are exempt from all treatment charges.

More information on ordinary residence. exemptions and paying for NHS services can be found in the Visitor and Migrant patient leaflet available from your GP practice.

You may be asked to provide proof of entitlement in order to receive free NHS treatment outside of the GP practice, otherwise you may be charged for your treatment. Even if you have to pay for a service, you will always be provided with any immediately necessary or urgent treatment, regardless of advance payment.

The information you give on this form will be used to assist in identifying your chargeable status, and may be shared, including with NHS secondary care organisations (e.g. hospitals) and NHS Digital, for the purposes of validation, invoicing and cost recovery. You may be contacted on behalf of the NHS to confirm any details you have provided.

Please tick one of the following boxes:

A parent/guardian should complete the form on behalf of a child under 16

Complete this section if you live in another EEA country, or have moved to the UK to study or retire, or if you live in the UK but work in another EEA member state. Do not complete this section if you have an EHIC issued by the UK.

NON-UK EUROPEAN HEALTH INSURANCE CARD (EHIC), PROVISIONAL REPLACEMENT CERTIFICATE (PRC) DETAILS and S1 FORMS

EHIC Card

If you are visiting from another EEA country and do not hold a current EHIC (or Provisional Replacement Certificate (PRC))/S1, you may be billed for the cost of any treatment received outside of the GP practice, including at a hospital.

Do you have a non-UK EHIC or PRC?

Do you have a non-UK EHIC or PRC?

If yes, please enter details from your EHIC or PRC below:

 

How will your EHIC/PRC/S1 data be used? By using your EHIC or PRC for NHS treatment costs your EHIC or PRC data and GP appointment data will be shared with NHS secondary care (hospitals) and NHS Digital solely for the purposes of cost recovery. Your clinical data will not be shared in the cost recovery process.

Your EHIC, PRC or S1 information will be shared with The Department for Work and Pensions for the purpose of recovering your NHS costs from your home country.

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