Visit Record form DoctorDate MM slash DD slash YYYY Time Hours : Minutes AM PM AM/PM Patient Name First Last If patient under 18 parent’s or guardian name: First Last Date of Birth MM slash DD slash YYYY Sex Male Female Patient Contact NumberPatient Email Address Visit Location / Address Street Address Address Line 2 City County / State / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Patient Home Address Street Address Address Line 2 City County / State / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Existing Patient at LGP? Yes No Presenting HistoryPast Medical HistoryRecent Travel HistoryOther Relevant History (Family)Drug HistoryAllergies (inc drugs)Patient ConsentConsent obtained to examine patient Yes No Chaperone Offered Yes No Chaperone Present Yes No Clinical FindingsBP: Pulse: SATS: Temp: LMP ♀:DiagnosisManagementPatient Consent: Medication side effects discussed? Yes No Patient Consent: Inform other Doctor? Yes No If yes, add details below (Inform other Doctor)InvestigationsMedication Dispensed / Administered? Yes No Medication detailsMedication / Batch No / Expiry date / Site administeredFollow up required? Yes No Please detail hereCharges/ServicesTotalConsent I understand and have agreed for the above charges in relation to today’s visit. I hereby consent to the release of my clinical notes to The Staight Practice.In this section "Data Protection Laws" means the Data Protection Act 2018, the Privacy and Electronic Communications (EC Directive) Regulations 2003 and any other Applicable Law relating to the processing, privacy or use of Personal Data; and "Personal Data" shall have the meaning given to it in the relevant "Applicable Law" with Personal Data including sensitive Personal Data and special categories of Personal Data. "Applicable Law" shall mean all applicable statutes, regulations, orders, regulatory requirements, by laws, ordinances, rules, subordinate legislation and other laws, including any judicial or administrative interpretation of them, in force from time to time in any applicable jurisdiction. The London General Practice (LGP) is committed to protecting and respecting patient privacy and to complying with Data Protection Laws and medical confidentiality guidelines. We have procedures in place to ensure that your information is kept safe, and that your Personal Data are kept confidential at all times. Please tick each of the boxes below if you agree to LGP processing and sharing your Personal Data (whether obtained by LGP and whether obtained at LGP or another hospital or surgery) in the way described: Please note that you can opt out at any time from any of the data processing and data sharing initiatives described below (although this will not affect the lawfulness of any processing of your Personal Data up to that point). If you change your mind at a later date please contact us here: info@thelondongeneralpractice.com.Family or Nominated Contacts You agree to the processing and sharing of Personal Data about the progress of your treatment with your nominated contact(s).Information about LGPFrom time to time LGP would like to inform you about new treatments, facilities, services, and offers. If you want to receive information about products and services from LGP, please let us know by ticking the relevant boxes below: Post Telephone Email Consent to Leave Voicemail Messages Containing Medical InformationBy ticking the box below, you consent to LGP leaving voicemails containing your medical information on the phone number(s) listed on this Patient Registration Form. This information may include, but is not limited to, demographic information (patient name, date of birth, address, etc.), billing information, and medical information (appointment dates, diagnosis, medications, test results, etc.). Please tick this box if you wish for LGP’s staff to leave voicemails containing your medical information.Consent to send Un-Encrypted EmailsFor your security emails sent out by LGP containing confidential patient data (e.g. clinical information) are encrypted using Egress Software to ensure information can be exchanged securely. Please tick this box if you consent to The London General Practice (TLGP) contacting you by un-encrypted email. Information included in these emails may include, but is not limited to, demographic information (patient name, date of birth, address, etc.), billing information, and medical information (appointment dates, diagnosis, medications, test results, etc.). In ticking this box you are accepting the risks associated with receiving unencrypted results via email.Data Protection - Agreement and Declaration 1. You may be receiving care from other people as well as employees of LGP. So that we all work together for your benefit, LGP may need to share some information about you with those people or organisations, and they may wish to send your information to companies/individuals outside the European Economic Area to support subsequent care. Medical information will be disclosed to those involved with your treatment or care at LGP and, if applicable, to any person or organisation or their agents or service providers within and outside the European Economic Area to carry out Service (which may include transcription of medical notes) and support your subsequent or ongoing care. 2. LGP will share your (or where applicable, your Guarantor or Sponsor's) non-medical information in relation to billing, processing, payment or collection of accounts, or credit referencing information. This extends to any person or organisation they may involve in order to achieve this. LGP will employ appropriate measures to protect your personal data where this is the case. 3. LGP has regulatory and/or compliance obligations to share certain clinical data with various governmental and regulatory bodies (for example the Care Quality Commission). This may include any personally identifiable clinical information, including your NHS patient identification number or its equivalent.AGREEMENT, DECLARATION AND CONSENTI acknowledge and understand I confirm that I have read, understood and accept the terms and conditions outlined above. I understand that I am personally responsible for any costs associated with my procedure if these costs are not covered by medical insurance, insurer or other third party such as a guarantor. I undertake to settle all personal expenses, cost of treatment at the time of my departure or upon request. I give permission to LGP or any other health care professional involved in my care, to access health information about me that is relevant to my treatment, which may be held by LGP, other health professionals or health organisations. I confirm that the information I have provided in this registration form is a true reflection of my current health and past medical history.Patient SignatureDate MM slash DD slash YYYY If you are not the patient please state relationship to the patient
