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. 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 request1. Patient InformationYour Name Title Mr.Mrs.MissMs.Dr.Prof.Rev. Given Name Family Name Known as OptionalDate of birth MM slash DD slash YYYY Resident in Jersey since MM slash DD slash YYYY Jersey Social Security NumberDo you hold a Green Health Card?YesNoPatients 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 IdentityMaleFemaleNon-binaryAgenderTransOtherMarital StatusSingleMarriedDivorcedWidowedSeparatedDomestic PartnershipEthnicity (a)WhiteBlackAsianMixedOtherEthnicity (b)BritishEuropeanOtherFirst Language (if not English) OptionalReason 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 provider2. Home Address and Contact InformationCurrent home address House Name / Flat Name Number & Street Parish / Town Postcode Mobile Tel No.Home Tel No. OptionalWork Tel No. OptionalConsent to receive SMSYesNoPersonal Email Address Email Address Confirm Email Address Consent to receive emailsYesNoPreferred Method of ContactEmailPhoneOnce fully registered, would you like us to activate your online access?YesNoThis will allow you to use the Patient Access App where you can place your repeat prescription requests and book appointments3. Emergency Contact / Next Of Kin InformationName Title Mr.Mrs.MissMs.Dr.Prof.Rev. Given Name Family Name Date of birth Optional MM slash DD slash YYYY Relationship to the patientDo you give consent to discuss your record?YesNoIs this your Next Of Kin?YesNoIs this your Official Carer?YesNoHome address House Name / Flat Name Optional Number & Street Optional Parish / Town Optional Postcode Optional Mobile Tel No.Home Tel No. OptionalWork Tel No. OptionalEmail Address Optional 5. Children aged under 16 and you are Parent/GuardianRegistrations Form to be completed for all those registering with the practiceChildren Full Name and Date of Birth Optionallist here all your children6. Private Medical Insurance and Current Employer InformationThe Patient is responsible for making all claims with their insurer. Bills must be paid by the patient and ask insurance for reimbursement.EmploymentEmployed Full-TimeEmployed Part-TimeSelf-employedNot employed but looking for workNot employed and not looking for workHomemakerRetiredStudentPrefer Not to AnswerWork IndustryAccounting/FinanceAdvertising/Public RelationsAerospace/AviationArts/Entertainment/PublishingAutomotiveBanking/MortgageOrganisation DevelopmentOrganisation OpportunityClerical/AdministrativeConstruction/FacilitiesConsumer GoodsCustomer ServiceEducation/TrainingEnergy/UtilitiesEngineeringGovernment/MilitaryGreenHealthcareHospitality/TravelHuman ResourcesInstallation/MaintenanceInsuranceInternetJob Search AidsLaw Enforcement/SecurityLegalManagement/ExecutiveManufacturing/OperationsMarketingNon-Profit/VolunteerPharmaceutical/BiotechProfessional ServicesQA/Quality ControlReal EstateRestaurant/Food ServiceRetailSalesScience/ResearchSkilled LaborTechnologyTelecommunicationsTransportation/LogisticsOtherCurrent Employer OptionalInsurance Provider Optional7. Previous/Existing GP InformationThis will be used to request previous medical record informationGP Name OptionalName of GP PracticeTel No. OptionalReason for transferring8. Patient Declaration, Confidentiality Agreement, Personal Data Statement and CommunicationPersonal 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. Select AllFurther 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. Select All 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. Select AllSignaturePrint NameRegistration Request Date MM slash DD slash YYYY Photo IDMax. file size: 1 GB.Valid passport, driving license or identity cardProof of addressMax. file size: 1 GB.Utility bill dated within 3 months; this document must have your nameGreen Health CardMax. 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 presented9. Medical History/AssessmentSummary 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: Optional10. Other Medical HistoryAllergies: Do you have any known or diagnosed allergies or adverse reactions to drugs, medication or other?YesNoIf YES please provide details OptionalMedication: Do you currently take any medication?YesNoIf YES please provide details OptionalFor female patients onlyCervical Screening (aged 25 and over): OptionalI have been screenedI have never been screenedLast screening date Optional MM slash DD slash YYYY Last screening result: OptionalMammography Screening (aged 50 and over): OptionalI have been screenedI have never been screenedLast screening date Optional MM slash DD slash YYYY Last screening result: Optional11. Your Exercise and Social ActivitiesExercise taken on a normal weekly basis Cycling including to work and leisure timeNoneLess than 1 hour1 to 3 hoursAbove 3 hoursWalking including to work and leisure timeNoneLess than 1 hour1 to 3 hoursAbove 3 hoursGardening/DIYNoneLess than 1 hour1 to 3 hoursAbove 3 hoursWhich sports or other exercises do you do? OptionalHow would you describe your walking pace?SlowSteadyBriskFastPhysical exercise such as swimming, jogging, sports, gym workoutNoneLess than 1 hour1 to 3 hoursAbove 3 hours12. 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 HistoryWhat is your current smoking status?Never SmokedEx-Smoker (please fill in section 13.1)Current Smoker (please fill in section 13.2)13.1 For Ex-SmokersWhen did you quit? Optional MM slash DD slash YYYY What products did you smoke? OptionalCigarettesCigarsPipeVapeIf 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 SmokersWhat products do you smoke? OptionalCigarettesCigarsPipeVapeIf 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? OptionalYesNoHave you considered or previously tried quitting? OptionalYesNoWhat made you start smoking again? OptionalWould you like advice on the Help2Quit Stop Smoking service in Jersey? OptionalYesNoOther Smoking InformationIf 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? OptionalYesNoDo you or other smokers smoke inside your home? OptionalYesNoAre there any persons under the age of 18 in the home who may open to a passive smoking risk in your home? OptionalYesNo14. Alcohol ConsumptionHow often do you have a drink containing alcohol?NeverMonthly or less2-4 times p/month2-3 times p/month4+ times p/weekHow many units of alcohol do you drink on a typical day when you are drinking01-23-45-67-910+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?NeverLess than monthlyMonthlyWeeklyDaily or almost dailyHow often during the last year have you found that you were not able to stop drinking once you had started?NeverLess than monthlyMonthlyWeeklyDaily or almost dailyHow often during the last year have you failed to do what was normally expected from you because of your drinking?NeverLess than monthlyMonthlyWeeklyDaily or almost dailyHow often during the last year have you needed an alcoholic drink in the morning to get yourself going after a heavy drinking session?NeverLess than monthlyMonthlyWeeklyDaily or almost dailyHow often during the last year have you been unable to remember what happened the night before because you had been drinking?NeverLess than monthlyMonthlyWeeklyDaily or almost dailyHave you or somebody else been injured as a result of your drinking?NoYes, but not in the last yearYes, during the last yearHas a relative or friend, doctor or other health worker been concerned about your drinking or suggested that suggested that you cut down?NoYes, but not in the last yearYes, during the last yearComments OptionalThis field is for validation purposes and should be left unchanged.
