Poole Town Registration Form

Women only
Do you require contraception?

Yes No
If yes please provide details
Are you currently pregnant?

Yes No Possibly
If yes please provide details
Do you have any children ?

Yes No
If yes how many children?

Students only

Students are at risk of certain infections including mumps, meningitis and sexually transmitted diseases, as well as mental health issues including stress, anxiety and depression.
I am less than 24 years old and have had 2 doses of the MMR vaccination

Yes No Unsure
I am less than 25 years old and have had Meningitis C vaccination

Yes No Unsure

SystmOnline

With SystmOnline you can access your local GP services at home, work or on the move - wherever you can connect to the internet. What’s more, because SystmOnline is a 24 hour online service you can do this in your own time, day or night.
I would like to have access to your clinic system to enable me to:
- Book and appointment with a Go online
- Order repeat prescriptions
- Update my mobile and email details
- send a secure message to you
- View my medical record - allergies and immunisations
I would like to have access to my detailed coded medical record *

Yes No
By signing this form you agree to the following:
- I will be responsible for the security of the information that I see or download.
- If I choose to share information with anyone else,this is at my own risk.
- If I suspect that my account has been accessed by someone without my agreement,I will contact the practice as soon as possible.
- If I see information in my record that is not about me or inaccurate,I will contact the practice as soon as possible.
- If I think that I may come under pressure to give access to someone else unwillingly I will contact the practice as soon as possible
Signature *

Clear
Date

Day Month Year
Date

Consent to use Mobile number

If you have registered with the practice and given us a mobile number, we would like to use this to send you text messages relating to your health. This may include reminders of appointments, and health campaigns e.g. Flu, Shingles etc.
I agree to the practice using my mobile number to send text messages about my health *

Yes No

Do I need ID to register?
You do not have to provide ID when registering with a GP, but it is helpful to do so. It is helpful if you can provide at least one of the documents below when registering with your GP:
PassportBirth certificateBiometric residence permit Travel documentHC2 certificateARC cardUtility bill

Passport Birth certificate Biometric residence permit Travel document HC2 certificate ARC card Utility bill
Please up load a copy of your ID

Cancel of

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 of the European Economic Area must also have the status of 'indefinite leave to remain' in the UK.

Some services,such as diagnosis 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 excempt from all treatment charges.

You maybe asked to provide proof of entitlement in order to receive free NHs treatment outside of the GO practice, otherwise you maybe charged.

The information you give on this form will be used to assist in identifying your chargeable status, and maybe shared, including with secondary care organisations.
I understand that I may need to pay for NHS treatment outside of the GP practice I understand I have a valid exception from paying for the NHS treatment outside of the GP practice. This includes for example, an EHIC, or payment of the immigration Heakth Charge when accompanied by a visa. I can provide document when requested. I do not know my chargeable status
I declare that the information I give on this form is correct. I understand that if it is not correct, appropriate action maybe taken against me.

Clear
Date

Day Month Year
Date
Should be Empty:

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Poole Town Registration Form

If you are from abroad

Medical History

Lifestyle

Women only

Students only

Further details

Data sharing

SystmOnline

Consent to use Mobile number

Do I need ID to register?

Patient Declaration for all patients who are not ordinarily resident in the UK