New Patient Health Questionnaire

Summary Care Records (SCR) is an electronic record of important information about a patient’s health. The summary care record is uploaded from General Practice clinical systems subject to a patient opting out.

What information is included in the Summary Care Record?

It will initially have information about current medications, allergies and any adverse reactions to medication. Additional information may be added over time.

If you require further information about the Summary Care Record then go to: www.nhscarerecords.nhs.uk

You can choose whether you want your record uploaded from our clinical system onto the Summary Care Records by opting out.

Please indicate below if you wish to opt-ou of the Summary Care Record:

Please read the conditions listed and confirm below if you are in agreement with these conditions of acceptance onto the Patient List for Dr Gupta's Practice.

• The surgery operates a zero tolerance policy. Any verbal or physical abuse against Doctors or surgery staff will not be tolerated and will result in immediate removal from our patient list.
• Unnecessary and/or immediate demands of any kind will not be accepted.
• The out of hours service is for EMERGENCIES ONLY.
• All requests for home visits must be received before 10.00am. These may be telephone triaged by a GP before they are accepted.
• If you are unable to attend or no longer need your appointment, we ask that you contact the surgery asap so that the appointment can be offered to someone else.

This form collects your name, date of birth, email, other personal information and medical details. This is to confirm you are registered with the practice, to allow the practice team to contact you and also to update your medical records held by the practice and our partners in the NHS. Please read your Practice’s Privacy Policy to discover how we protect and manage your submitted data.