NEW PATIENT REGISTRATION FORM

GUARANTEED SAME DAY OR NEXT DAY APPOINTMENTS, OR YOUR APPOINTMENT WILL BE FREE

BECOME A PATIENT WITH WINDSOR MEDICAL TODAY

Windsor Medical is under new management and we are taking on new patients that are struggling to see their existing GP.

With a new team of caring GP’s, friendly reception staff, and a refurbished surgery, Windsor Medical is a welcoming surgery for patients in ST Helier with a patient -first approach.

The first 1000 new patients to register with us, will benefit from our ‘Patient Promise’ - which means if we do not see you the same day, or the next day, your appointment will be completely free.

To get started, fill in the form below and once submitted, our friendly team will be in touch to complete your registration.

Title

Gender Identity

Name

First Name

Last Name

Marital Status

Date of Birth

YYYY

Ethnicity

Reason for registering with the practice

Jersey SS Health Card no

Not required for visitors

Phone number

(###)

###

####

Current Home Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Jersey Home Address

To be completed by visitors only

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Emergency Contact Information

First Name

Last Name

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone number

(###)

###

####

Is this your next of Kin?

Yes

Relationship to the patient

Consent to discuss your records

Yes

Private Medical Insurance & Current Employer Details

Please provide your insurance provider and Policy scheme number

Medical History

Allergies: Do you or the child have any known allergies or do you have any adverse reaction to drugs or medication? If the answer is yes please provide details.

Medication

Do you or the child currently take any medication? If yes please provide details.

Do you or the child suffer from any significant ongoing medical problems or had any serious illnesses/ operations in the past? If yes please specify.

Existing GP details

Please provide GP Name, Address and Telephone number.

Patient Decleration, Confidentiality Agreement, Personal Data Statement and Communication.

In the case of a child under the age of 16, This declaration should be signed ‘for and on behalf of’ the child named on this registration form by the Parent/Legal Guardian as given in section 4. Your Personal Information (Data Protection and Patient Privacy): The information collected on this application form will be used by WINDSOR MEDICAL PRACTICE (hereafter the ‘Practice’) for the purposes of healthcare related services and practice administration. Personal information we hold about you 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. 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): 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. 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. You do however have the right to ‘opt out’ of sharing some or all of your medical records. Please ask us for more information and where 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.

Print name

Parent/Legal Guardian if for child named below)

First Name

Last Name

Child Name

First Name

Last Name

Date of birth

YYYY

NEW PATIENT REGISTRATION FORM

We’re Windsor Medical, and we’re by your side.

Windsor Medical Practice

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