Additional new patient registration

Medication

Are you on any repeat medication? *

Yes

No

Do you have a repeat prescription slip from your previous GP? *

Yes

No

Please hand this slip in at the Dispensary if you are in need of urgent medication. Otherwise, please bring this to your new patient medication review appointment with the GP.

If you do not have a repeat prescription slip, please show any current medication you are taking to Dispensary. This needs to be in its original packaging and labelling. We may need to contact your previous GP surgery to confirm your medication.

If you live within 1.6 miles distance of a local pharmacy, you are not eligible to collect medication from the Dispensary at Aldborough Surgery. Please choose your local pharmacy for the Electronic Prescription Service (EPS).

Preferred location for prescriptions: *

Dispensary (if eligible)

Chosen pharmacy

Which pharmacy: *

Females Only

Are you pregnant?

Yes

No

Expected due date:

If you have a Coil, Implant or injection, please let us know the last date this was fitted/injected:

Consent to view/discuss your record

As a patient, you may give permission for someone else to discuss your medical information on your behalf with a GP, medical secretary or other health professional. This information may include, for example; test results, appointments, medications or your general health. The third party could be a family member, friend or neighbour. If you don’t wish to nominate someone at this stage but change your mind, third party consent forms are available from Reception or you can give verbal consent to a Doctor or Nurse during a consultation.

Would you like to give permission for someone else to discuss your medical information on your behalf with a GP, medical secretary etc?

Yes

No

Their full name:

Their relationship to/with you:

Their telephone number:

Online Services – SystmOnline – Patient Access

In association with our clinical software provider we are able to offer you the facility to:

Book and cancel appointments.
Request prescriptions for repeat medication.
View your coded medical record.
View test results.

Patients can use Patient Access from a PC, a mobile phone or any other device that they use to access the internet. Before you can use the online service, you must visit the practice in person and obtain a login PIN number and Access ID code from our Dispensary Team. You must bring 1 form of photographic identification such as a current driver’s licence or passport.

Do you wish to register for Aldborough Surgery online services? *

Yes

No

Sharing Information with other NHS Organisations and your Summary Care Record.

Aldborough Surgery advocates the safe, controlled and proportionate sharing of your medical record with other NHS organisations involved in your care. This includes organisations such as the Hospital or the Community Nursing Team who wouldn’t automatically have full access. We also support the creation of an Enhanced Summary Care Record for each of our patients which is a summary of key information (such as current medication, allergies, adverse reactions and additional information) that can be viewed by any Emergency NHS Service (such as the Hospital and Out of Hours Service) when you need to be seen urgently, anywhere in the country.