Online Adult Primary Registration Form (adults aged 16 or over)

Individual patient registration forms must be completed for each adult and young person over the age of 16. Please complete clearly all relevant sections of this registration form.

Adult Primary Registration Form

When completing this form make sure you have with you a Photo ID, Utility bill dated within 3 months and your Social security card or green health card. You’ll be required to upload these documents in order to complete your registration request. Once your details are added to the system you will be classed as ‘Pre-Registered’ and your request will be reviewed after a month. You will be contacted to book a New Patient Screen which is a requirement for your registration review. Please note that while ‘pre-registered’, payment must be done when requesting a service

1. Patient Information

Your Name

Title Given Name Family Name

Known as Optional

Date of birth

Resident in Jersey since

Jersey Social Security Number

Do you hold a Green Health Card?

Patients need a health card to get a subsidy when visiting General Practitioners (GPs). Health cards are issued if a resident has lived in Jersey for at least 6 months and have paid Social Security contributions. For the first 6 months after arriving in Jersey, new residents don’t hold a health card and will have to pay the full cost should they need to visit a GP or another health care provider.

Gender Identity

Marital Status

Ethnicity (a)

Ethnicity (b)

First Language (if not English) Optional

Reason for registering with the Practice

Transferring from another Jersey GP Practice

Re-registering with GP Practice

New resident in Jersey

NOTE: New residents in Jersey are charged the full cost for the 1st 6 months, should they need to visit a GP or another health care provider

2. Home Address and Contact Information

Current home address

House Name / Flat Name Number & Street Parish / Town Postcode

Mobile Number

Landline Number Optional

Consent to receive SMS

Personal Email Address

Email Address Confirm Email Address

Consent to receive emails

Preferred Method of Contact

Once fully registered, would you like us to activate your online access?

This will allow you to use the Patient Access App where you can place your repeat prescription requests and book appointments

3. Emergency Contact / Next Of Kin Information

Name

Title Given Name Family Name

Date of birth Optional

Relationship to the patient

Do you give consent to discuss your record?

Is this your Next Of Kin?

Is this your Official Carer?

Home address

House Name / Flat Name Optional Number & Street Optional Parish / Town Optional Postcode Optional

Phone Number

Email Address Optional

5. Children aged under 16 and you are Parent/Guardian

Registrations Form to be completed for all those registering with the practice

Children Full Name and Date of Birth Optional

list here all your children

6. Private Medical Insurance and Current Employer Information

The Patient is responsible for making all claims with their insurer. Bills must be paid by the patient and ask insurance for reimbursement.

Employment

Work Industry

Current Employer Optional

Insurance Provider Optional

7. Previous/Existing GP Information

This will be used to request previous medical record information

GP Name Optional

Name of GP Practice

Tel No. Optional

Reason for transferring

8. Patient Declaration, Confidentiality Agreement, Personal Data Statement and Communication

Personal Information (Data Protection and Patient Privacy):

I understand that the information collected on this application form will be used by First Medical Ltd (hereafter the ‘Practice’) for the purposes of healthcare related services and practice administration.

I understand that personal information First Medical hold about me is processed for the purposes of ‘Employment and Social Fields’ (Article 8) ‘Medical Purposes’ (Article 15) and ‘Public Health’ (Article 16) of the Data Protection (Jersey) Law 2018.

I understand that this may require your personal data including, relevant details of your medical history, to be shared with other approved healthcare providers for the purpose of referrals and for other lawful purposes related to the Practice procedures.

Further information on how we hold and process your data can be found in our Data Protection and Patient Privacy Policy.

General Practice Central Services (GPCS):

I understand that all Jersey GP Practices and other approved healthcare service providers, such as the out-of-hours doctors, use a central medical records system known as EMIS.

I understand this allows access to a ‘shared medical record’ to ensure that the provider or clinician has immediate up-to-date and accurate information about your health and any current treatment you may be having.

I understand that I have the right to ‘opt out’ of sharing some or all of my medical records. I can ask the practice for more information and if appropriate an Opt-in/Out Form for completion.

All approved healthcare service providers with authorised access to GPCS have signed strict confidentiality agreements which are bound by the Data Protection (Jersey) Law 2018.

Your Declaration to us:

• I confirm that all the information I have given in this registration form is accurate to the best of my knowledge.

• I understand that the Practice has the right to accept or decline my registration application at any time.

• I understand that by attending a consultation with a GP or other healthcare professional of the Practice, I accept the Practice terms of service and fee schedule issued and displayed in the Practice premises and as amended from time to time.

• I hereby agree to pay any incurred service fees from the Practice at the time of attendance or treatment.

• I expressly consent that on registration or prior to accepting any credit arrangement from the Practice, where appropriate a credit reference check may be taken with an authorised credit reference agency and/or my previous medical practice(s).

• I give my express permission for the Practice to request information including my medical records from my previously registered GP and I agree to reimburse the Practice for any charges and disbursements incurred relating thereto for the Practice being provided with such information.

• I understand it is my sole responsibility to advise the Practice in writing of any changes made in respect of my personal information.

Signature

Print Name

Registration Request Date

Photo ID

Max. file size: 1 GB.

Valid passport, driving license or identity card

Proof of address

Max. file size: 1 GB.

Utility bill dated within 3 months; this document must have your name

Green Health Card

Max. file size: 1 GB.

if you don’t hold a green card, please upload copy of your Social Security Card. However, without a green health card you will be charged full price until the card is presented

9. Medical History/Assessment

Summary Medical History (tick if you have ever had any of the following)

Diseases of the nervous system e.g. neuritis, stroke, multiple sclerosis

Chest pain, angina, heart disease or breathlessness

Raised or low blood pressure

Asthma, bronchitis, emphysema, pneumonia or any other lung disease

Any metabolic disorder including diabetes, thyroid and adrenal gland disease

None of the above

Please provide further information that you feel may be relevant to your current or past medical history: Optional

10. Other Medical History

Allergies: Do you have any known or diagnosed allergies or adverse reactions to drugs, medication or other?

If YES please provide details Optional

Medication: Do you currently take any medication?

If YES please provide details Optional

For female patients only

Cervical Screening (aged 25 and over): Optional

Last screening date Optional

Last screening result: Optional

Mammography Screening (aged 50 and over): Optional

Last screening date Optional

Last screening result: Optional

11. Your Exercise and Social Activities

Exercise taken on a normal weekly basis

Cycling including to work and leisure time

Walking including to work and leisure time

Gardening/DIY

Which sports or other exercises do you do? Optional

How would you describe your walking pace?

Physical exercise such as swimming, jogging, sports, gym workout

12. Family Medical History (If Known)

Tick if a family member has ever had any of the following:

Select All Optional

Heart Disease Optional

Hypertension Optional

Diabetes Optional

Cancer Optional

Mental Health Optional

13. Smoking History

What is your current smoking status?

13.1 For Ex-Smokers

When did you quit? Optional

What products did you smoke? Optional

If you used to smoke cigarettes, how many on an average day?

< 1 Optional

1-9 Optional

10-19 Optional

20-39 Optional

40+ Optional

13.2 For Current Smokers

What products do you smoke? Optional

If you smoke cigarettes, how many on an average day?

< 1 Optional

1-9 Optional

10-19 Optional

20-39 Optional

40+ Optional

If you vape, do you use both tobacco products and vaping together? Optional

Have you considered or previously tried quitting? Optional

What made you start smoking again? Optional

Would you like advice on the Help2Quit Stop Smoking service in Jersey? Optional

Other Smoking Information

If you smoke cannabis or any other products not recorded above, it is advisable to discuss your use confidentially with your GP, so that they can advise you appropriately on any potential smoking risks to you.

Are there other smokers in your home? Optional

Do you or other smokers smoke inside your home? Optional

Are there any persons under the age of 18 in the home who may open to a passive smoking risk in your home? Optional

14. Alcohol Consumption

How often do you have a drink containing alcohol?

How many units of alcohol do you drink on a typical day when you are drinking

How often have you had 6 or more units if female, or 8 or more if male, on a single occasion in the last year?

How often during the last year have you found that you were not able to stop drinking once you had started?

How often during the last year have you failed to do what was normally expected from you because of your drinking?

How often during the last year have you needed an alcoholic drink in the morning to get yourself going after a heavy drinking session?

How often during the last year have you been unable to remember what happened the night before because you had been drinking?

Have you or somebody else been injured as a result of your drinking?

Has a relative or friend, doctor or other health worker been concerned about your drinking or suggested that suggested that you cut down?

Phone Optional

This field is for validation purposes and should be left unchanged.