New Patient Registration

If you would like to register with the Practice please use this form.

IT IS VERY IMPORTANT THAT YOU PROVIDE AS MUCH INFORMATION AS POSSIBLE

Once you have completed the form you will need to come into the Practice with one proof of ID and one proof of address to complete your registration (Driving Licence, Passport, Utility bill etc). For children we will need a copy of their birth certificate or passport so we can verify their name and date of birth.

Please allow 2-3 working days for us to process your registration before visiting the surgery.  At the same we will register you for Patient Online Services, and you will be able to collect your log on details again from our Reception.

All of our new patients are required to attend a ‘new patient’ appointment, so that we can introduce you to our Practice, establish your current state of health, check your blood pressure and offer further services as appropriate. Once registered please make an appointment to attend the surgery at your earliest convenience.

Practice Area

You can register at the Practice if you live in our area. Please see our Practice Patient Boundary Map.

Please not that the Upper Heyford housing development is outside of our Practice area.

NHS Number

Please obtain your NHS Number from your old Practice if you don’t know it.  We require this to ensure that you are registered correctly and that we can transfer your medical records to us.

Temporary Registration

If you are ill while away from home or if you are not registered with a doctor but need to see one you can receive emergency treatment from the local GP practice for 14 days. After 14 days you will need to register as a temporary or permanent patient.

Overseas Visitors

For Guidance on overseas visitors please visit www.GOV.UK  for further information.

If you have a EHIC card /PRC/S1, how will you 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.

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

Use of Texts, Emails and Messaging

Mobile – Texts: To improve our service to patients we send appointment and medical review reminders by text, and encourage patients to opt in to this.

Home Phone – Messages: We are trialing phone voicemail so we can send appointment and medical review reminders to patients who do not have a mobile phone. Patients access the message by entering their date of birth into their phone.

For further information on our use of texts,emails and messaging, and the safeguards in place, please see our Information Technology page.

Dispensary & Prescriptions

We dispense directly to patients who live more than a mile (as the crow flies) from a community pharmacy; we currently dispense to 3,500 patients.  To see if this applies to you please use our mapping tool. Please sign up to this service if applicable.

Our on-site dispensary is open between 08:30 and 18:00

Electronic Prescription Service (EPS)

We use the EPS.  This means your prescription is sent electronically to whichever pharmacy you have elected to use, saving both time and cost as well as being more convenient for you.

Summary Care Record

A Summary Care Record is an electronic record used nationally across England and is available to authorised healthcare professionals who care for you in urgent or emergency situations . This might be if you are ill when you are away from home or when your GP surgery is closed. It is based on your GP record and contains key information to support emergency care such as: medicines you take; any allergies you have; or any bad reactions you have had to medicines. This is now created automatically for you.  You can opt to include Additional Information, including significant medical history, medication, management of long term conditions, end of life care, immunisations and communication preferences (Sensitive information like fertility treatment STIs, pregnancy terminations etc are not automatically included unless you request them to be included). We recommend that you OPT IN to Additional Information being included in your SCR.  

The Oxfordshire Care Summary is similar, but contains additional information for healthcare providers you may have need to use in Oxfordshire (e.g. A&E, Out of Hours doctor, District Nurse etc). We recommend that you OPT IN to this.  

An information leaflet is available here for the Oxfordshire Care Summary 

Patient Consent to Share Medical Information

For patients 16 years and over who wish to provide access to their medical information to a 3rd party such as a carer, family member or close friend, then a “Patient Consent – Share Medical Information” form is required. This can be printed off our Website (see Practice Information) or is available from our Patient Services.

Patient Online Services

By using our Patient Online Services you can make a GP appointment, make repeat prescriptions and view any test results 24/7 on your mobile, tablet or PC.  For more information see here.

We recommend that you signed up to this.

For Patients 14 years and older Proxy Access can be given to a 3rd Party by completing the “Patient Consent – Share Medical Information ONLINE” form. This can be printed off our Website (see Practice Information) or is available from our Patient Services.

Please read the information in the left hand column BEFORE completing this form.

PATIENT'S DETAILS

Please use this date format: DD/MM/YYYY.
If you were previously registered at another practice please contact the practice to obtain your NHS No.
This allows us to send you appointment Text reminders
If you don't provide an email address we won't be able to respond to you by email

By providing these details you consent to us contacting you with personal confidential medical details or results

Nationality

Emergency Contact - Patients 16 Years and Over

For patients 16 yrs and over - for patients who wish to provide access to their medical information to a 3rd party such as a carer, family member or close friend, then a “Patient Consent – Share Medical Information” form is required. Please download the form and return this to the surgery.

Learning Disability

Please use this date format: DD/MM/YYYY.

Carers

For patients who wish to provide access to their medical information to a 3rd party such as a carer, family member or close friend, then a “Patient Consent – Share Medical Information” form is required. Please download the form and return this to the surgery.

Prescriptions

If you live further than 1 mile from a community pharmacy you will be able to use our Dispensary to obtain your medication – this is known as being a “Dispensing Patient”

To see if this applies to you please use our Dispensary Eligibility mapping tool

Summary Care Record and Oxfordshire Care Summary - your choice

Please note that these records are used only for the purpose of enabling informed care to be supplied directly to you as an individual.

You patient record is held securely and confidentially on the electronic system at your GP Practice. If you require treatment in another NHS healthcare setting such as an Emergency Department or Minor Injury Unit, those treating you would be better able to give you appropriate care if some of the information from the GP practice were available to them.

This information can now be shared electronically via:
1. The Summary Care Record: used nationally across England
2. The Oxfordshire Care Summary: used locally across Oxfordshire

In both cases, the information will be used only by authorised health care professionals directly involved in your care. Your permission will be asked before the information is accessed, unless the clinician is unable to ask you and there is a clinical reason for access.

A patient or guardian can request to opt out children under 16 ultimately it is the GPs decision whether to create the records or not, because of their duty of care to the child. If you are the parent or guardian of a child under 16 and feel that they are able to understand, then you should make this information available to them.

Are you happy for us to share this electronic information with clinicians in other NHS organisations who are involved in your care? If you would rather we didn't, we will put an entry on your record which will prevent your information from being shared.

In England a Summary Care Record (SCR) is automatically created for you unless you opt out. If you wish to opt out please contact the Practice.

NHS Organ Donor registration

If you would like to join the NHS Organ Donation Register please visit their website on: www.organdonation.nhs.uk/consent.do

NHS Blood Donor registration

If you would like to join the NHS Blood Donor Register as someone who may be contacted and would be prepared to donate blood, please visit their website on: www.blood.co.uk or call direct on 03001232323

PREVIOUS DETAILS

Help us trace you medical records by providing the following information

Please include postcode.

Are you visiting or moving to the UK from overseas?

Please use this date format: DD/MM/YYYY.

If you are returning from abroad

Previously been a resident in the UK

Please use this date format: DD/MM/YYYY.
Please use this date format: DD/MM/YYYY.

Overseas Visitors Accessing Healthcare in the UK

Ordinarily Resident

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. Alternatively for more information go to www.nhs.uk/visitingengland.

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.

I declare that the information I give on this form is correct and complete. I understand that if it is not correct, appropriate action may be taken against me.

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

European Economic Area (EEA) Country

For a list of EEA countries visit: www.gov.uk/eu-eea

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.

EHIC/PRC

Please enter the details from your EHIC or PRC below.

S1 Form

Please give your S1 form to the practice staff.

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.

Are you returning from the Armed Forces?

MEDICAL HISTORY

Child under 16 years

Child under 5 years

Information for child health records

Immunisations - Please ensure the following immunisation history is completed fully with actual dates from the child's "Red Book" or medical record document.

Age Usually Given - 2 Months

Diphtheria, tetanus, pertussis, polio and Hib - Please use date format as DD/MM/YYYY
Please use date format DD/MM/YYYY
Please use date format DD/MM/YYYY
Please use date format DD/MM/YYYY
Please use date format DD/MM/YYYY

Age Usually Given - 3 Months

Diphtheria, tetanus, pertussis, polio and Hib - Please use date format DD/MM/YYYY
Please use date format DD/MM/YYYY
Please use date format DD/MM/YYYY

Age Usually Given - 4 Months

Diphtheria, tetanus, pertussis, polio and Hib - Please use date format DD/MM/YYYY
Please use date format DD/MM/YYYY
Please use date format DD/MM/YYYY
Please use date format DD/MM/YYYY

Age Usually Given - 12 - 13 Months

Please use date format DD/MM/YYYY
Please use date format DD/MM/YYYY
Please use date format DD/MM/YYYY
Please use date format DD/MM/YYYY

Age Usually Given - 3 yrs 4 months approx.

Please use date format DD/MM/YYYY
Diphtheria, tetanus, pertussis, polio - Please use date format DD/MM/YYYY

Non Routine Vaccines

Please use date format DD/MM/YYYY
Please use date format DD/MM/YYYY
Please use date format DD/MM/YYYY
Please use date format DD/MM/YYYY

Declining Child Vaccinations

If you have decided for your child not to have a vaccination(s), you will need to complete a signed declaration so we can update their medical record. Please download and complete the Child Vaccination(s) - Declined Form, sign and return it to the Practice.

Current Conditions

Please include dates.
Please include dates.

Immunisation History

Please include dates.

Allergies

Adult Females only

Please use this date format: DD/MM/YYYY.

LIFESTYLE

Alcohol Consumption

This is one unit of alcohol:

And each one of these, is more than one unit:

This is your total score from the Alcohol Consumption section.

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 has access to your records is 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.

Adults only: You will be invited shortly to attend a New Patient Health Check, where we can also offer lifestyle advice and support. If possible please bring a sample of urine when you attend – containers are available from our Reception.

In the meantime please visit our Advice and Help Zone for information on national and local support for a variety of conditions, including stopping smoking, keeping healthy, Drugs and Alcohol, Autism and much more.

For Office use only: