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Hampshire Health Record
Call 111 - When it is less urgent than 999

New Patient Registration - Adults

We do not tolerate aggressive, threatening or abusive behaviour towards any staff and Patients will be removed from our practice list if there are occurrences of unacceptable behaviour

New Patient Registration - Adults

What do we use your phone numbers & Email address for?

We may leave a message, send you texts or emails for: Appointment reminders Information regarding health campaigns such as Flu vaccinations Message you regarding test results / messages from a General Practitioner If you do not wish to be contacted in this way please let reception know.

Do you consent to be contacted by

If yes, please provide:

Please help us trace your previous medical records by providing the following information
If you are from abroad
Were you ever registered with an Armed Forces GP

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 need your doctor to dispense medicines and appliances*

* Not all doctors are authorised to dispense medicines

NHS Organ Donor registration

The law has changed so that you now need to opt out if you do not want to become a Donor. It is important that you talk to your family about your organ donation decision as they will be asked to support your decision. If you are undecided or do not want to become an organ donor please contact the NHS Organ Donation website at or 0300 123 23 23.

NHS Blood Donor registration

All blood types are needed, especially O negative and B negative. Visit or call 0300 123 23 23.

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.


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.

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.

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.

Ethnicity Monitoring

Having information about patients' ethnic groups would be helpful for the NHS so that we can plan and provide culturally appropriate and better services to meet patients' needs. If you do not wish to provide this information, you do not have to do so. You may indicate this by ticking the last box. Your answer to this question will not affect your care.

Next of Kin

Please note that this consent will remain in place until your inform us otherwise

Nominated Pharmacy
Communication Requirements

This carer’s information will remain in place until you inform us otherwise

Patient Participation Group

Smoking Cessation advice contact Quit For Life on 0845 6024663, Text – QUIT to 60123 or email

Lifestyle alcohol
Data Sharing and You

Medical Records & Data Sharing explained: As part of the NHS, our surgery aims to provide you with the highest quality of health care. To do this we must keep records about you, your health and the care we have provided or plan to provide to you. These records may include:

• Basic details about you such as address, telephone number, date of birth, next of kin • Contact we have had with you such as clinical visits • Notes and reports about your health • Details and records about your treatment and care, including test results • Relevant information from people who care for you and know you well such as health professionals and relatives

Everyone working for the NHS has a legal duty to keep information about you confidential. We have a duty to maintain full and accurate records of the care we provide to you. Some information will be held centrally to be used for statistical purposes. In these instances we take strict measures to ensure that individual patients cannot be identified. We use anonymous information, wherever possible, but on occasions we may use personal identifiable information for essential NHS purposes such as research and auditing.

We will not share information that identifies you for any reason unless: • You ask us to do so • We ask and you give us specific permission • We have to do this by law • We have special permission for health and research purposes, or • We have special permission because the interest of the public are thought to be of greater importance than your confidentiality, for example, if you had a serious medical condition that may put others you may have come into contact with at risk • When we use this information we make sure that, wherever possible, we do not use personal details such as your name and address, in order to protect your confidentially. When releasing information to researchers, we give them only the minimum data necessary and all their research is carefully vetted.

At the surgery there are three main organisations with which we share your data

Summary Care Record

There is a national NHS Computer System called the Summary Care Record (SCR). This is an electronic record, which contains information about the medicines you take, allergies you have and any bad reactions to medicines you may have had. Having this information stored in one place makes it easier for healthcare professionals to treat you in an emergency, or if your GP practice is closed. This information could make a difference to how a doctor decides to care for you, for example which medicines they choose to prescribe you.

You can add more information such as your health problems, carer details or communication needs to your SCR. This is called an enhanced SCR so if you ever need treatment away from your GP surgery, health care staff will have a better understanding of your needs and preferences.

For further information visit the NHS Digital website

Care and Health Information Exchange (CHIE)

The Care and Health Information Exchange (CHIE) is a secure system which shares key parts of your electronic record from GP surgeries, hospitals, community, mental health and social services. It allows health professionals across Hampshire and the Isle of Wight to provide safer and faster treatment for you and your family.

Care and Health Information Analytics (CHIA)
Your information is also used to improve future care for you, your family and for other patients. This helps plan NHS services and supports medical research. To keep your information safe it is moved to a separate database called ‘Care and Health Information Analytics’ (CHIA) and changed so that it cannot be used to identify you. Your data is never shared for the benefit of commercial companies like drug manufactures. People who analyse data on CHIA do not have access to CHIE, so cannot identify you.

Privacy Protection

Information submitted through secure forms is used only for the purposes of processing your request. We may be in touch with you in relation to the information submitted.

All Information submitted through secure forms is secured with a private key and is accessed over a secure connection by nominated staff. We have a strict confidentiality policy.

This information is not shared with any third party organisations.

This information is retained for up to 28 days.

Learn more about our Privacy Policy and Terms of Use. Should you have any concerns about sending your personal details using the web, please use one of the alternative methods offered by our organisation.

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