How to register - online registration form

To register as a patient at Sunnyside Medical Centre we need you to complete our registration form. You can do this by completing the online form below (or by visiting the surgery to pick up a ‘hard copy’ of the form). If you are registering more than one patient (including family members) you will need to complete a form for each person, as we need very specific information regarding personal details and medical history.

Please ensure you are using a ‘modern’ web browser such as Google Chrome, Microsoft Edge, Firefox etc. Older browsers such as Internet Explorer may not allow you to submit the form at the end due to their security vulnerabilities.

If you have any questions about registration please contact us at ssmc.sunnyside@nhs.net or calling 02392 812 481.

New Patient Registration Form

Form for patients to use to register with Sunnyside Medical Centre. Current version 1 - 202107

Step 1 of 8

REGISTERING AT SUNNYSIDE MEDICAL CENTRE

Welcome to Sunnyside Medical Centre and thank you for your interest in registering as a new patient. Prior to completing a registration form, please ensure the following:

You should only send this form to us if you are sure that you are eligible to join our practice.
Sending this form will not automatically register you with the surgery.
Your details will be held at the surgery for a limited period of time.
You are required to provide proof of your identity and address within 2 weeks of completing this form..
To submit this form you will need to agree to our privacy notice and information governance agreement which supports you in knowing and understanding how we look after your personal data.
Finally, you need to be using a modern web browser such as Chrome, Microsoft Edge, Firefox etc to complete this form. Old browsers (such as Internet Explorer) may not allow you to complete the form validation at the end.

If you require on the day treatment, our urgent care team run a triage service twice a day. Please telephone between 08:00 – 11:00 and 14:30 – 16:00 for this service. Please be aware, our reception team will ask for a brief outline of the problem, this is to ensure that those people who require treatment sooner are dealt with in an appropriate length of time. You might also be signposted to a more appropriate service, for example physiotherapy, pharmacy or dentist. Please telephone between 08:00 – 11:00 and 14:30 – 16:00. This is a limited service so we advise calling as soon as possible. If the clinician feels you require a face to face appointment, they will arrange this with you.

We encourage the use of e-consult for all routine and administrative issues, the link for this can be found on our website. If you do not have access to a computer or smart phone, our reception team can assist you by collecting details of your problem in a similar way over the phone. A clinician will then be in contact with you within a few days. They will contact you by telephone, email or SMS.

The surgery offers face to face services when they are essential; e.g. when a clinician needs to physically examine you. Patients with long term conditions, for example diabetes or asthma, will be invited in by the practice for a yearly annual review. Please see our website or ask at reception for more information. All Nurse and HCSW appointments can be booked by calling the surgery, e.g. regular injections, dressings, contraception, essential bloods and blood pressure.

privacy notice

Acknowledgement(Required)

Please tick to confirm that you have read and understand the above information.

I have read and understand the above information.

Are you currently serving, a military veteran or reservist

Currently serving

Reservist

Military veteran / ex forces

Which branch of the forces (most recent service)

Army

Navy

Airforce

Veterans / Ex-forces - Date of Discharge

Please note - If this is your first GP Registration after discharge we will require your discharge medical records.

Do you have any family member currently still in military service?

Yes

Next of Kin (NoK) and Carer Details

Please provide Details of your Next of Kin

NoK Name(Required)

Title First Last

NoK Relationship to you (free text)(Required)

Next of Kin Address (if different to your own)

Street Address Address Line 2 Town or City County Post Code Country

NoK Phone Number(Required)

Is your Next of Kin registered at Sunnyside Medical Centre?(Required)

Yes

Carer Information

Are you a Carer?(Required)

Yes

Do you have a carer or somebody that looks after you?(Required)

Yes

Are you housebound?(Required)

Yes

Details of the person you care for or your carer?

First Last

Additional Services

Text and email Reminder Service. Do you consent to text and/or email messages from Sunnyside?(Required)

This service will allow Sunnyside Medical Centre to contact you via text and/or email message. These are now the preferred method of communication due too low costs, the ability to send efficiently to multiple patients and the speed by which we can contact you. This has been particularly useful during the COVID pandemic. Examples of text usage include sending appointment reminders, providing information about new services (for example invitations for vaccines) and sending guidance and links.

Both text and email are fine

Text Only

Email Only

No thank you, please use post

Application for access to SystmOnline

All patients can have access to their medical records, appointment booking, requesting medication, questionnaires, summary record access and full clinical record access using online services. By ticking below you are agreeing to accept responsibility for the password and any access to the system using the password; I am aware that if I divulge the password or allow access to the system to third parties then they will be able to access personal information about me. I agree to inform the practice immediately if I believe that my login details have been lost or stolen.

Yes, please set up access to SystmOnline

No thank you.

Record Sharing - please only tick if you wish to OPT OUT of record sharing.

Medical Record Sharing - Summary care record

This is a summary of your medication, allergies and adverse reactions. This can only be accessed by a clinician in England and with your expressed consent. This includes all hospitals and any healthcare professional.

I wish to OPT OUT of sharing my Summary Care Record

Medical Record Sharing - Out of hours services and secondary care (for example, hospitals)

I wish to OPT OUT of sharing my record with out of hours and secondary care services.

This allows access to your FULL health record to OOH (out of hours) services and secondary care clinicians in Portsmouth only, and WILL help with your care.

We agree to adhere to the following:

1. All contact details held by the practice will only be used by the practice to deliver health care and will not be passed to any other parties. You will not be contacted in relation to other types or products or services.
2. If at any time you would like to opt out of this service, please make a personal request to the practice and we will remove your permission within 48 hours.
3. If at any point contact number is to change, please inform us as soon as possible.

Final Submission Agreement

Sunnyside Medical Centre - Consent(Required)

I agree to the privacy policy detailed below.

Summary Privacy Notice
• This practice handles all our records according to the laws on data protection and confidentiality.
• We share medical records with other NHS health professionals who are involved in providing you with care and treatment. This is on a need to know basis and event by event.
• Some of your data is automatically copied to the Shared Care Summary Record
• Data about you is used to manage national screening campaigns such as Flu, Cervical cytology and Diabetes prevention.
• Data about you, usually anonymised, is used to manage the NHS and make payments.
• We share information when the law requires us to do, for instance when we are inspected or reporting certain illnesses or safeguarding vulnerable people.
• Your data is used to check the quality of care provided by the NHS.
• We may also share medical records (usually anonymised) for medical research
For more information please read the Privacy Notice pages on our website.

Identification(Required)

I agree that I will visit the surgery within two weeks of submission of this form with my identification.

CAPTCHA

This helps to prove your are a 'real person' and not a random computer filling in forms to block up our systems and generate junk mailing opportunities.

Once you submit this form we will send you a confirmation email, then we will await your identification prior to creating your patient record. Once we have your identification we will create your record within 5 working days.

How to register – online registration form

New Patient Registration Form

Next of Kin (NoK) and Carer Details

Carer Information

Medical History and Medication

Current Medication

Lifestyle Information

Height and Weight

Additional Services

Record Sharing - please only tick if you wish to OPT OUT of record sharing.

Final Submission Agreement