Change of Address - Out Of Area | Webform Portal

Change of Address - Out of Area

This form is for EXISTING PATIENTS only moving to an address outside of the practice catchment area but who wish to remain registered at St Wulfstan Surgery. Please note this form must be completed for each member of the household who wish to become and out of area patient.

This is your application to become and 'Out Of Area' patient at St Wulfstan Surgery. The GP's will assess if it clinically appropriate and practical in each individual case to accept the registration.

Please be aware that:

- As an Out of Area patient you will not be eligible for home visits. In the case of ebing too ill to attend the surgery and the practice not being able to help you over the phone, you will need to call 111 who will advise you on local services.

- If your health deteriorates and you develop a longer-term need for care in your home we would probably advise you to register with a local practice that would provide home visits.

First name: *

First name

Surname: *

surname

Date of Birth *

DOB

Previous Address *

Previous Address

Home Telephone Number

Mobile Number *

Mobile Number

Email *

Email

New Address *

New Home Telephone Number

Children Under 16 Included

Child	Date of Birth

COMMUNICATION NEEDS

Communication Needs - for those with a disability, impairment or sensory loss. We aim to ensure that people who have a disability, impairment or sensory loss receive information that they can access and understand, for example, large print, braille or by providing professional communication support such as British Sign Language interpreter. If you have such a need please let us know about it below.

I communicate with the support of:

a hearing aid British Sign Language lip reading Other:

If you have ticked other please indicate here how you communicate

I specifically require contact by:

telephone letter email SMS other

If you have ticked other please indicate how you require contact

I would like to receive information:

verbally in Easyread in braille in large print other

If you have ticked other please indicate how you would like to receive information

Preferred Pharmacy - Please specify which pharmacy you would like any future prescriptions sent to *

ONLINE PATIENT SERVICES

If you have an existing online service account for booking appointments and ordering repeat prescriptions, your link to the GP practice will cease when you are re-registered. We will email you a new PIN document to enable you to re-link your account. PLEASE ENSURE YOU HAVE PROVIDED US WITH AN EMAIL ADDRESS. If you do not have an exisitng online service account but would like one please visit https://terrier-mouse-e3yw.squarespace.com/online-services

ALCOHOL SCREENING

How often have you had 6 or more units (if female) or 8 or more (if male) on a single occassion in the last year?

Never (0) Less than monthly (1) Monthly (2) Weekly (3) Daily or almost daily(4)

How often during the last year have you failed to do what was normally expected from you because of your drinking?

never (0) Less than monthly (1) Monthly (2) Weekly (3) Daily or almost daily (4)

How often during the last year have you been unable to remember what happened the night before because you had been drinking?

Never (0) Less than monthly (1) Monthly (2) weekly (3) Daily or almost daily (4)

Has a relative or friend, doctor or other health worker been concerned about your drinking or suggested you cut down?

No (0) yes but not in the last year (2) yes during the last year (4)

PERMISSION TO CONTACT YOU

We need your permission to contact you with infromation about health issues that may be important. Please indicate your preferences below. (This does not relate to SMS appointment reminders and test results).

Phone SMS email

SUMMARY CARE RECORD

The NHS Summary Card Record is an electronic record of important information about your health. It will be given to health carestaff providing your NHS care and includes infromation such as current medications, allergies and adversereactions to medicineyou have had. If you chose to, you can also opt to include additional informationabout your illness, health problems, operations and vaccinations you have had in the past and your preferences as to where and how you receive care.

I do not wish to have a Summary Care Record I do wish to have a Summary Care Record for medication allergies and adverse reactions only I do wish to have a summary care record for medication allergies adverse reactions and additional information

I confirm all the above information is correct and I agree to the conditions of Out of Area registration. *

Tap or click on the signature above to sign

WHAT HAPPENS NEXT?

The doctors will make a decision regarding your application. Not all applications will be suitable for this type of registration. We will only register you as an Out of Area patient if it is clinically appropriate and practical in your individual case. You will be sent confirmation by SMS once a decision has been made. This is normally within 24 hours. You will receive another SMS notification once the registration has been completed. This is normally within 48-72 hours but can take longer if there are delays with Primary Care Services England through whom registrations are processed. Please be assured that you remain a registered patient with us during this time.

FOR OFFICE USE ONLY

Reception - address update SMS sent confirming approval deduction requested Re-registered SMS sent confirming registration PIN documents emailed LG notes amended Approved by GP (initials) Processed by (initials)