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The information you provide in this form will be processed by Cedar Practice. The information will be treated as confidential and stored in a secure data centre located in the UK. The information will be uploaded to your record in the practice’s clinical system as soon as possible after submission, after which the copy of your information in the data centre will be securely destroyed.
Please note that by using this form you will be sending information about yourself across the Internet. Whilst every effort is made to keep this information secure, you should be aware that we cannot offer any guarantees of absolute privacy. If this matter concerns you then you should use another method of providing this information.
You have the right to revoke this Consent to the terms laid here, in writing, signed by you. However, such a revocation shall not affect any disclosures we have already made in reliance on your prior Consent.
Cedar Practice is committed to ensuring that its services are accessible to everyone regardless of race, gender, ability, religion, sexual orientation or age. The information you give on this page will help us comply with our policy of ensuring equality in our services to you.
We recognise that some people may regard some of this information as personal and we have, therefore, included an option in most questions for 'prefer not to say'. You do not have to complete this page, but it will help our services if you can complete as much as possible.
All information collected around equality and diversity will be treated confidentially in accordance with the Data Protection Act. Access to this information will be restricted to the staff involved in the processing and monitoring of this data. It will be used to provide statistical information only.
Please tick one box that best describes your ethnic group or background from the options below:
Please tick one box that best describes your religious beliefs from the options below:
Please tick one box that best describes your sexual orientation from the options below:
Do you consider yourself to have a disability according to the terms given in the DDA?
Have you ever suffered from? (tick as appropriate)
1 drink = 1/2 pint of beer or 1 glass of wine or 1 single spirits
If you are registered with a GP practice in England you will already have a Summary Care Record (SCR), unless you have previously chosen not to have one. It will contain key information about the medicines you are taking, allergies you suffer from and any adverse reactions to medicines you have had in the past.
Information about your healthcare may not be routinely shared across different healthcare organisations and systems. You may need to be treated by health and care professionals that do not know your medical history. Essential details about your healthcare can be difficult to remember, particularly when you are unwell or have complex care needs.
Having a Summary Care Record can help by providing healthcare staff treating you with vital information from your health record. This will help the staff involved in your care make better and safer decisions about how best to treat you.
You have the choice of what information you would like to share and with whom. Authorised healthcare staff can only view your SCR with your permission. The information shared will solely be used for the benefit of your care.
Your options are outlined below:
a) Express consent for medication, allergies and adverse reactions only. You wish to share information about medication, allergies and adverse reactions only.
b) Express consent for medication, allergies, adverse reactions and additional information. You wish to share information about medication, allergies and adverse reactions and further medical information that includes: Your significant illnesses and health problems, operations and vaccinations you have had in the past, how you would like to be treated (such as where you would prefer to receive care), what support you might need and who should be contacted for more information about you.
c) Express dissent for Summary Care Record (opt out). Select this option, if you DO NOT want any information shared with other healthcare professionals involved in your care.
Please note that it is not compulsory for you to complete this consent form. If you choose not to complete this form, a Summary Care Record containing information about your medication, allergies and adverse reactions and additional further medical information will be created for you as described in point b) above.
You are free to change your decision at any time by informing your GP practice.
If you require any more information, please visit http://digital.nhs.uk/scr/patients or phone NHS Digital on 0300 303 5678 or speak to your GP practice.
Anybody in England can register with a GP practice and receive free medical care from that practice.
However, if you are not 'ordinarily resident' in the UK you may have to pay for NHS treatment outside of the GP practice. Being ordinarily resident broadly means living lawfully in the UK on a properly settled basis for the time being. In most cases, nationals of countries outside the European Economic Area must also have the status of 'indefinite leave to remain' in the UK.
Some services, such as diagnostic tests of suspected infectious diseases and any treatment of those diseases are free of charge to all people, while some groups who are not ordinarily resident here are exempt from all treatment charges.
More information on ordinary residence, exemptions and paying for NHS services can be found in the Visitor and Migrant patient leaflet, available from your GP practice.
You may be asked to provide proof of entitlement in order to receive free NHS treatment outside of the GP practice, otherwise you may be charged for your treatment. Even if you have to pay for a service, you will always be provided with any immediately necessary or urgent treatment, regardless of advance payment.
The information you give on this form will be used to assist in identifying your chargeable status, and may be shared, including with NHS secondary care organisations (e.g. hospitals) and NHS Digital, for the purposes of validation, invoicing and cost recovery. You may be contacted on behalf of the NHS to confirm any details you have provided.
Cedar Practice, John Scott Health Centre,
Green Lanes, corner of Springpark Drive,
Hackney, London, N4 2NU
© Cedar Practice 2024