WELCOME TO - Undercliffe Surgery
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V2 June 2020
WELCOME TO
UNDERCLIFFE
SURGERY
New Patient Registration Form - Aged 16 and Over
Thank you for your enquiry regarding our practice. Our registration process will take between 5 and 10
working days to be completed, once all documentation has been received.
In order to register with Undercliffe Surgery you must complete the entire registration procedure and follow
the instructions listed below in full.
All parts of this registration form must be completed in full.
Personal identification must be provided for every adult. Documents that are accepted are listed on
the next page. Registrations cannot be completed until these documents are provided.
Provide proof that the patient is living permanently at an address that is in our practice boundary.
Documents that are accepted are listed on the next page. Registrations cannot be completed until
these documents are provided.
The completed registration pack can be returned via post or by placing in the post box on the side of
the surgery building.
Copies of the personal identification and proof of address documents must be emailed to
nkccg.undercliffe@nhs.net (PLEASE NOTE: this email address is for the submission of registration
documents only. Emails relating to anything else will be deleted and not acted upon). Please include
your full name and address as listed on the registration form and state that the documents are in
relation to a patient registration.
The email containing your documents MUST be received by Undercliffe Surgery within 5 working
days of the submission of the registration form. Registration forms will be securely destroyed after 5
working days if personal identification and proof of address documents are not received.
Every adult will receive a text message from the surgery asking them to make a telephone
appointment for their New Patient Health-Check Screening.
On the day of the pre-arranged telephone New Patient Health-Check Screening we will contact you
using the telephone numbers you have given on your registration form. We will attempt to contact
you three times, if you do not answer any of these calls your registration will not be completed.
If the New Patient Health-Check Screening telephone appointment is not undertaken within 4 weeks
of registration date your registration will not be completed.
IF YOU NEED MEDICATION OR AN APPOINTMENT WHILST WAITING FOR YOUR
REGISTRATION TO BE COMPLETED THEN THIS SHOULD BE WITH YOUR CURRENT
GP OR YOU CAN ATTEND THE LOCAL WALK-IN-CENTRE WHICH IS SITUATED AT
DEWSBURY HOSPITAL.
FAILURE TO COMPLETE THE REGISTRATION PROCESS IN FULL AND FOLLOW
THESE INSTRUCTIONS WILL RESULT IN YOUR APPLICATION BEING IMMEDIATELY
REJECTED AND YOU WILL NOT BE REGISTERED AT OUR PRACTICE.
If you do not wish to follow our registration processes you can apply to the local Health Authority who will
allocate you to another practice.V2 June 2020
TO BE COMPLETED BY THE SURGERY
It is a requirement of our contract to allocate and inform you of your named GP. Having a named GP does
not prevent you from seeing any other clinician at this practice.
Your named GP is: Dr Goodwin
Dr Hartwell
Dr Hussain
PROOF OF IDENTITY AND ADDRESS
All patients wishing to register with Undercliffe Surgery must provide proof of identity and proof of
address documents at the time of registration via email to nkccg.undercliffe@nhs.net .
Patients must submit one item from List 1 OR two items from List 2 as proof of identity, AND 1
item from list 2 for proof of address. The same document cannot be used as proof of identity and
proof of address.
List 1
UK passport or EU/other nationalities passport
UK full or provisional photo-card driving licence
HM Armed Forces Identity card
ID cards carrying the PASS accreditation logo
List 2 * These items cannot be used for proof of address
Birth certificate*
Marriage certificate*
Medical card*
An education certificate gained from an institution regulated or administered by a Public
Authority or from a well-recognised higher educational institution *
Bank/building society card with corresponding statement (no more than 3 months old)*
National insurance number card*
Bus pass (current)*
Local authority rent card
Private rent book/rental agreement
Utility bill (no more than 3 months old)
Payslip (no more than 3 months old)
Benefits Agency book/signing on card (no more than 6 months old)
Documents from the Home Office (no more than 6 months old)
P45 (no more than 12 months old)
Non-bank savings account statement
Non-bank credit account (including credit/store/charge cards)V2 June 2020
IMPORTANT INFORMATION
Surgery Opening Times Contact us
Telephone: 01924 403406
Regular Hours 8.00am – 6.30pm Fax: 01924 412890
Monday to Friday Website: www.undercliffe.gpsurgery.net
Email: nkccg.undercliffe@nhs.net
Your local doctors and healthcare providers are working to improve access to GP appointments and reduce
attendance at A&E departments. We believe that the best place for you to be seen for your healthcare
needs is your local GP surgery – where your practice team know you best.
Curo Health Limited is working together with your GP to provide an extended hours service that offers
routine medical treatment and advice. This service is available between 6.30pm and 9.00pm on Mondays
to Friday and 9.00am to 1.00pm Saturday and Sunday. All appointments are delivered from Liversedge
Medical Centre. Appointments can be booked via our Patient Liaison team or calling 01924 925517 when
the service is open.
At all other time when the surgery is closed and you feel that you need urgent healthcare advice, contact
NHS 111. All calls are free to this number.
Alternatively, you may wish to consult with your local pharmacist, who may be able to help you with:
Skin conditions (mild acne or eczema)
Coughs, colds, nasal congestion and sore throats
Minor cuts and bruises
Constipation and haemorrhoids (piles)
Hay fever and allergies
Aches and pains (headache; earache or backache)
Indigestion, diarrhoea and threadworms
Period pain and thrush
Warts, verruca’s, mouth ulcers and cold sores
Athlete’s foot
Nappy rash and teething
Travel medicines, sun creams and treatments for insect bites
Head lice treatments
Creams for bruising, tattoos and varicose vein
Earwax removers
You can also find advice and ‘fact sheets’ for common minor aliments on the Self Care Forum at
www.selfcareforum.org.
For advice on colds, flu, and sore throats you may wish to visit the ‘Symptom Checker’ at
www.treatyourselfbetter.co.uk
For a wide range of health advice and information visit NHS Choices at www.nhs.uk.V2 June 2020
WHAT YOU CAN EXPECT FROM OUR GP SURGERY
The table below explains what you can expect from your GP Surgery and how you can help us provide the
best service work for you.
YOU CAN EXPECT US TO: WE EXPECT YOU TO:
Ensure you are treated respectfully at all times Treat our staff with respect
Help us maintain our records by providing us with up
Protect your privacy and dignity and maintain
to date information (e.g. telephone number/change of
confidentiality at all times
address)
Attend your appointments or let us know that you
Provide a safe, clean environment for you to attend
can’t make your appointment
Accept any request for a telephone ‘call back’ for
Listen to the advice given and ask if you are unclear
queries on health issues or if further clarity is needed
about the information given
following an appointment, where possible
If you require a more urgent appointment please call
Listen advise and sign-post patients to appropriate
the surgery as early as possible in the day to allow
services
time to access a health professional
Speak to the reception staff if in certain
Provide a number of ways to order prescriptions
circumstances if you find yourself without medication
including on line, fax, repeat prescription box, face to
A&E and out of hours are not the services to be used
face
for medication
Provide a variety of booking options including an on- Call the surgery for appointments rather than
line appointment booking service attending A&E, unless life is at risk
Call the surgery if you are waiting for an appointment
Offer a flexible booking system to allow timely
and your health deteriorates rather than attending
appointment availability
A&E.
Aim to see all children under 5 years old on the same
Be prepared to attend at any time during the day
day, if they are unwell and offer further appointments
when you ring for an appointment
should the problem persist
Be patient at busy times. If the clinic is running late,
Help and advise you on an appropriate way in which
remember it might be you that needs the extra time
to order and collect your prescription
next visit!V2 June 2020
REGISTRATION FORM - 16 AND OVER
PATIENT DETAILS
Title Mr Mrs Ms Other Male Female
Marital Status Single Civil Partnership Married Separated Divorced Widowed
First Name Middle Names
Surname Previous Surname
Address
Postcode
Home Phone Number Mobile Number
Day Time Phone Number Email Address
Date of Birth (dd/mm/yyyy) Place of Birth
Nationality Ethnic Origin
Language Spoken English Speaker Yes No
Occupation
Employment Status Employed Self-Employed Unemployed Retired Student
IF YOU WERE NOT BORN IN THE UK PLEASE STATE THE DATE YOU ENTERED THE UK
Date Month Year
PREVIOUS DOCTORS DETAILS
Name of Doctor/Practice
Address
Postcode Telephone Number
NEXT OF KIN DETAILS
Full Name of Next of Kin
Relationship to You
Contact Telephone Number
Are they registered at Undercliffe Surgery? Yes NoV2 June 2020
DISABILITY AND CARER DETAILS
Are you registered as disabled? Yes No
Is your disability related to: Sight Hearing Mobility
Do you have a carer? Yes No
Are they registered at Undercliffe Surgery? Yes No
Full Name of your carer
Address of your carer
Are you a carer for someone else? Yes No
Are they registered at Undercliffe Surgery? Yes No
Full Name of person you care for
Address of person you care for
MEDICAL HISTORY
Have you or anyone in your family had any of the following medical problems? (Please circle appropriate)
PROBLEM PATIENT FAMILY PROBLEM PATIENT FAMILY
Arthritis Yes No Yes No Asthma Yes No Yes No
Tuberculosis Yes No Yes No Stroke Yes No Yes No
Cancer Yes No Yes No Chronic Bronchitis Yes No Yes No
Diabetes Yes No Yes No Epilepsy Yes No Yes No
Thyroid Trouble Yes No Yes No High Cholesterol Yes No Yes No
High Blood Pressure Yes No Yes No Glaucoma/Blindness Yes No Yes No
Heart Attacks or
Angina Yes No Yes No Ulcer (duodenal/gastric) Yes No Yes No
Depression/Any Other Yes No Yes No
Depressive Illnesses
Have you had any other illness, accident or operations in the past? Yes No
If yes, please give details
DESCRIPTION HOSPITAL YEAR
Are you under the care of a hospital specialist at the present time? Yes No
SPECIALIST HOSPITAL DIAGNOSISV2 June 2020
MEDICATIONS
Are you taking any medicines or tablets at the present time? Please list below
MEDICATION DOSE OR STRENGTH HOW MANY TIMES PER DAY
Please attach the tear off slip of your repeat medications so we can input this information onto the
system
Recreational Drugs?
ALLERGIES
Do you have any allergies to medicines or tablets? Yes No
If Yes, please give details
Do you have any other allergies, e.g. bee stings, peanut allergy? Please give details
VACCINATIONS
When did you last have your Tetanus and Polio Booster?
Tetanus (date) Polio (date)
LIFESTYLE
Do you drink alcohol? Yes No How much per Day
Do you smoke? Yes No How many per day
Have you ever smoked Yes No How many did you smoke
How long ago did you stop smoking Years Months
Do you exercise? Yes No
What type of diet do you have?V2 June 2020
WOMEN
Have you ever been pregnant? Yes No If yes, how many pregnancies?
Have you ever had any problems connected with your pregnancies, difficult Yes No
deliveries, miscarriages, etc.
If Yes, please give details
Rubella status?
Are you using birth control now? Yes No
If Yes, please state which form you are using
When was your last smear test? Date Result
MILITARY VETERANS
NHS published guidelines recommend all service veterans should receive priority access to NHS care for any
condition which is likely to relate to their military service as many conditions do not become obvious until
after a veteran has left military service. Please tick if you have served time in any of the following:-
Army Navy Air Force
ADULTS AGED 75 YEAR AND 0VER
All patients aged 75 years and over are now given the opportunity to decide which doctor they would like to
nominate as their accountable GP.
Please indicate your preference below by ticking the appropriate box
Dr Goodwin
Dr Hartwell
Dr Hussain
No Preference
ADDITIONAL INFORMATION
Please detail any additional medical information you feel the doctor may need to know
PATIENT DECLARATION
I declare the information given in this form is correct
Patient Signature DateV2 June 2020
Your Electronic Patient Record & the Sharing of Information
- A Patient’s Guide
Patient Name __________________________________ Date of Birth ________________
Please read this leaflet carefully. It will give you information about the sharing of your electronic
patient record and the choices you need to make.
Summary Care Record
A Summery Care Record (SCR) contains patient demographics (name, date of birth, address etc.), any
known allergies and current medication. This gives other users access to this information who may need it
in emergencies i.e. Emergency Departments at hospital or the Ambulance Service. It is your decision if this
SCR is shared as described. You must state your preference below.
Opt In (SCR Shared) Opt Out (SCR Not Shared)
Signed Date
Please note that you can change your mind at any time please speak to the Reception Manager or
Practice Manager.
Sharing of Clinical Information Between Services Where You Are Treated
Electronic records are kept in all the places where you receive healthcare. These NHS Care Services can
usually only share information from your records by letter email, fax or phone. At times, this can slow down
your treatment and mean information is hard to access.
Your GP practice uses a computer system called SystmOne that allows the sharing of full electronic
records across different NHS Care Services. You have a choice to make about how your practice shares
information about your care from your electronic patient record. This is not about your Summary Care
Record (SCR), it is asking your sharing preferences regarding your full electronic GP record. You can
choose to share or not to share your electronic GP record with other NHS Care Services.
There are two settings that allow you to control how your medical information is shared:
Sharing Out – This controls whether your full GP electronic patient record can be shared with other NHS
Care Services where you are treated. Please record your preference:
Yes (full GP record shared with other healthcare teams) No (not shared)
Sharing In – This controls whether you agree for this practice to view information you’ve agreed to share
at other NHS Care Services. Please record your preference:
Yes (information from other services viewable by GP surgery) No (not viewable)
Signed Date
FOR OFFICE USE ONLY
REGISTRATION FORM ACCEPTED
STAFF NAME DATE
DOCUMENTS RECEIVED
STAFF NAME DATE
REGISTERED ON SYSTEM
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