Complete Your Registration Important This form is only for use by patients of Papworth Surgery. If you are not a patient please visit this page to register as a new patient. Complete Your Registration Welcome to Papworth Surgery To register for online services please ensure that you complete all required fields. This form can take up to 10 minutes to complete. If you would like any help with completing this form please visit the surgery. Paper versions of these registration documents are available on request. Registrations may take up to 5 days to be processed. "*" indicates required fields Please choose from the following*I am an existing patient at Papworth SurgeryI have registered as a new patient in the last 5 daysTitle* Mr Mrs Miss Ms Other Name* First names Surname Date of Birth*DD12345678910111213141516171819202122232425262728293031MM123456789101112YYYY202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920NHS Number (if known) OptionalFind your NHS numberAddress* Street Address Address Line 2 Town/City Postcode Main Contact Number*Alternative Contact Number OptionalEmail Optional Is English your first spoken language?* Yes No What is your first spoken language?* Preferred method of contact*Main Contact NumberAlternative Contact NumberEmailPlease provide a mobile telephone number wherever possible. By doing so, you will be automatically enrolled to our text reminder service. We will use this for: contacting you about your health when unable to contact you at home / texting your appointment reminders / responding to your queries / advising when your prescriptions/paperwork is ready / advising you if appointments are cancelled.Patients Fleeing the Conflict in UkraineAre you a patient fleeing the conflict in Ukraine?*NoYesDo you have a lack of appetite and weight loss?*NoYesDo you have a high temperature?*NoYesDo you have night sweats?*NoYesDo you have extreme tiredness or fatigue?*NoYesDo you have a persistant cough that lasts more than 3 weeks and usually brings up phlegm and/or blood?*NoYesDo you suffer from breathlessness that gradually gets worse?*NoYesDo you have any new swelling around the neck?*NoYesVerifying Your IDTo help us verify your ID, please choose 3 of these questions to answer. Please choose 3 different questions.Question 1*When did you last see your Doctor or Nurse?When did you last speak to your doctor or nurse on the telephone?Do you take any regular prescribed medication? If so, please list themHave you had an operation, and if so, at which hospital?What year did you join the Practice?Do you have a hearing aid?When did you last order your medication?Do you have any allergies?Do you have any Long Term Conditions? If so, please list themWhen did you join your previous Practice?Answer 1* Question 2*When did you last speak to your doctor or nurse on the telephone?Do you take any regular prescribed medication? If so, please list themHave you had an operation, and if so, at which hospital?What year did you join the Practice?Do you have a hearing aid?When did you last order your medication?Do you have any allergies?Do you have any Long Term Conditions? If so, please list themWhen did you join your previous Practice?When did you last see your Doctor or Nurse?Answer 2* Question 3*Do you take any regular prescribed medication? If so, please list themHave you had an operation, and if so, at which hospital?What year did you join the Practice?Do you have a hearing aid?When did you last order your medication?Do you have any allergies?Do you have any Long Term Conditions? If so, please list themWhen did you join your previous Practice?When did you last see your Doctor or Nurse?When did you last speak to your doctor or nurse on the telephone?Answer 3* Online AccessYou can now use the NHS App and Website to manage appointments, request repeat prescriptions for any medications you take regularly, check test results and look at your medical record online. Being able to see your record online helps you to manage your medical conditions. It also means that you can access it from anywhere in the world should you require medical treatment on holiday. The service is open 24/7/365 and can be accessed from your home PC, Tablet or Mobile phone Click here to find out more about the NHS App / NHS LoginSummary Care RecordThere are strict laws and regulations to ensure that your health records are kept confidential and can only be accessed by health professionals directly involved in your care. There is some sharing of information as detailed below. You can opt out of any of these at any time if you wish. NHS Summary Care Record (SCR) – this is an electronic record which contains information about the medicines you take, allergies you suffer from and any bad reactions to medicines you have had. Having this information stored in one place makes it easier for healthcare staff to treat you in an emergency, or when your GP practice is closed. If you need more time to make your choice you should let your GP Practice know. For more information talk to the Patient Experience Team on 0800 2792535 or [email protected], visit the Cambridgeshire & Peterborough Integrated Care System website, telephone the dedicated NHS Summary Care Record Information Line on 0300 123 3020, or visit their website, or contact your GP practice staff. You can choose not to have a Summary Care Record and you can change your mind at any time by informing staff at Papworth Surgery. If you do nothing we will assume that you are happy with these changes and create a Summary Care Record for you. If you would like further details on how to Opt Out and what this choice means, please visit the NHS Your Data Matters website.I agree to opt in or opt out*I agree to OPT-INI DO NOT agree to OPT-INOpt-OutWhat does it mean if I DO NOT have a Summary Care Record? NHS healthcare staff caring for you may not be aware of your current medications, allergies you suffer from and any bad reactions to medicines you have had, in order to treat you safely in an emergency. Your records will stay as they are now with information being shared by letter, email, fax or phone. If you have any questions, or if you want to discuss your choices, you can: – Phone the Summary Care Record Information Line on 0300 123 3020 – Contact your GP practice – Visit www.digital.nhs.uk/scr You can change your mind at any time. I wish to OPT-OUT and DO NOT want a Summary Care Record OptionalYour Health Record and Sharing of InformationSharing Out – This controls whether your information recorded at this Practice can be shared with other healthcare professionals. Sharing In – This determines whether or not this Practice can view information in your record that has been entered by other services who are providing care for you or who may provide care for you in the future. Please indicate your choices about sharing your health record.Sharing Out*I would like my health record at this Practice to be shared with other healthcare services providing care for me Yes No Sharing In*I would like this practice to be able to view information in my health record that has been recorded by other health care services Yes No Your DataYour Data*What happens to my information? Personal and medical information about patients registered at this practice are primarily kept electronically, although some is kept in paper form. Some information will be sent to hospital consultants and other health professionals to whom you are referred by your GP in order to provide continued healthcare and obtain treatment for you. We sometimes use accredited suppliers for our communication with you, for example when we send recall letters for review clinics or medication reviews. All suppliers we use are checked carefully to ensure they comply with strict confidentiality protocols To ensure the security of all patient information, all staff that have access to your records are covered by confidentiality clauses in their contracts and the Data Protection Act and the Freedom of Information Act. Our guiding principle is that we hold your records in strict confidence. I certify that the information I have provided is correct and consent to my personal and medical information being used as stated above.*Email OptionalThis field is for validation purposes and should be left unchanged.