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Albany House Surgery
Reception Area
About Us
Contact
Contact Telephone Numbers
Location
Signing Up For Patient Participation Group
Subject Access Request (SAR)
Ask Reception a Question
GP Training
Have your Say
Compliments and Suggestions
Complaints
Friends and Family Test
Patient Opinion
Patient Participation Group
Making the most of your Practice
Opening Hours
What to do when we are closed
Our Team
Doctors
Nurses
Practice Team
Our Allied Health Professionals
Practice Policies
At the Practice
Accessible Information Standard
Baby Friendly
Chaperones
Chaperone Policy
Clinical Governance
Clinical Research
Consent Protocol
Disability Access
Duty of Candour
Equality and Diversity
Infection Control Statement
Named GP Policy
Non-Smoking Premises
Quality Assurance
Removal of Patients from our List
Social Media
Safeguarding
Shared Decision Making
Unacceptable Actions Policy
Zero Tolerance
Data
Care Data
Freedom of Information
General Practice Extraction Service (GPES)
Your NHS Data Matters
Patient Record
Accessing your Record
Access for Others
Subject Access Requests(SAR)
Data Sharing Preferences
Multi-Disciplinary Teams
Organ Donation
Sharing your Information with Others
Summary Care Records (SCR)
How we use your Data
Confidentiality
Privacy Policy
Online Access
Proxy Access
Patient Rights
Complaints
Entitlement to NHS Treatment
Patient Advice and Liaison Service (PALS)
NHS Patient Rights
Your Rights and Responsibilities
Website
Accessibility
Copyright
Cookie Policy
Disclaimer
Regulations & Governance
Clinical Commissioning Group
GP Earnings
Care Quality Commission (CQC)
NHS Services
The NHS Constitution for England
Teenage Friendly
Can I see the GP or Nurse on my own?
Clinics & Services
Appointments, Tests & Referrals
Appointments
Book an Appointment
Cancel an Appointment
Extended Hours Appointments
Hospital Appointments – Book, Cancel or Change
Help with your GP Appointment
Know Who to Turn to for Your Healthcare
Accident & Emergency
Dentist
Hospitals
NHS Out of Hours Services
Optician
Pharmacist
Referral for Further Care
See a Doctor or Healthcare Professional
Tests & Investigations
Access Your Test Results
Other Common Tests
Urine Tests
X-Rays & Scans
What is a Blood Test?
Clinics
Antenatal Care
Cervical Screening – Smear
Child Health Checks
Child Health
Contraception / Family Planning Clinic
Our Clinics
Long Term Conditions
NHS Health Check aged 40 – 74
Postnatal Clinic
End of Life Care
Online Services
Routine Prescription Request
Register for Online Services
NHS App
Urgent Prescription Request
Practice Services
Advocacy Service
Age UK Free help and advice (Worcester & District)
Cervical Screening
Hepatitis B Immunisation
Housebound & Older People
Home Visits
Interpreting Service
New Medicine Service (NMS)
NHS screening
Non NHS Services – Chargeable
Prescriptions
Antibiotic Use
Wasted Medications
Electronic Prescriptions
Prescription request
Patient Transport Service
Register with us as a New Patient
Further Help about how to Register with a GP
GP2GP
Registration Policy
Temporary Services
Sick/Fit Note
Texting Service
Vaccinations
You & Your Health
COVID-19 Support
Health Review Forms
Asthma Review Form
Alcohol Consumption Review Form
Blood Pressure Review Form
Breathlessness Review Form
Epilepsy Review Form
Male Urinary Tract (IPSS) Review Form
Mental Health Review (PHQ-9) Form
Smoking Review Form
Travel Risk Assessment Form
Help & Support
Oxford hip and knee scores
Keep us up to Date
Change of Contact Details Form
Communication Consent Form
Register as a Carer Form
Register for Online Services Form
Summary Care Record Opt-out Form
Upload photos or documents
Who Do I See?
Private referral for appointment or scan
STAFF ONLY
Menu
Reception Area
About Us
Contact
Contact Telephone Numbers
Location
Signing Up For Patient Participation Group
Subject Access Request (SAR)
Ask Reception a Question
GP Training
Have your Say
Compliments and Suggestions
Complaints
Friends and Family Test
Patient Opinion
Patient Participation Group
Making the most of your Practice
Opening Hours
What to do when we are closed
Our Team
Doctors
Nurses
Practice Team
Our Allied Health Professionals
Practice Policies
At the Practice
Accessible Information Standard
Baby Friendly
Chaperones
Chaperone Policy
Clinical Governance
Clinical Research
Consent Protocol
Disability Access
Duty of Candour
Equality and Diversity
Infection Control Statement
Named GP Policy
Non-Smoking Premises
Quality Assurance
Removal of Patients from our List
Social Media
Safeguarding
Shared Decision Making
Unacceptable Actions Policy
Zero Tolerance
Data
Care Data
Freedom of Information
General Practice Extraction Service (GPES)
Your NHS Data Matters
Patient Record
Accessing your Record
Access for Others
Subject Access Requests(SAR)
Data Sharing Preferences
Multi-Disciplinary Teams
Organ Donation
Sharing your Information with Others
Summary Care Records (SCR)
How we use your Data
Confidentiality
Privacy Policy
Online Access
Proxy Access
Patient Rights
Complaints
Entitlement to NHS Treatment
Patient Advice and Liaison Service (PALS)
NHS Patient Rights
Your Rights and Responsibilities
Website
Accessibility
Copyright
Cookie Policy
Disclaimer
Regulations & Governance
Clinical Commissioning Group
GP Earnings
Care Quality Commission (CQC)
NHS Services
The NHS Constitution for England
Teenage Friendly
Can I see the GP or Nurse on my own?
Clinics & Services
Appointments, Tests & Referrals
Appointments
Book an Appointment
Cancel an Appointment
Extended Hours Appointments
Hospital Appointments – Book, Cancel or Change
Help with your GP Appointment
Know Who to Turn to for Your Healthcare
Accident & Emergency
Dentist
Hospitals
NHS Out of Hours Services
Optician
Pharmacist
Referral for Further Care
See a Doctor or Healthcare Professional
Tests & Investigations
Access Your Test Results
Other Common Tests
Urine Tests
X-Rays & Scans
What is a Blood Test?
Clinics
Antenatal Care
Cervical Screening – Smear
Child Health Checks
Child Health
Contraception / Family Planning Clinic
Our Clinics
Long Term Conditions
NHS Health Check aged 40 – 74
Postnatal Clinic
End of Life Care
Online Services
Routine Prescription Request
Register for Online Services
NHS App
Urgent Prescription Request
Practice Services
Advocacy Service
Age UK Free help and advice (Worcester & District)
Cervical Screening
Hepatitis B Immunisation
Housebound & Older People
Home Visits
Interpreting Service
New Medicine Service (NMS)
NHS screening
Non NHS Services – Chargeable
Prescriptions
Antibiotic Use
Wasted Medications
Electronic Prescriptions
Prescription request
Patient Transport Service
Register with us as a New Patient
Further Help about how to Register with a GP
GP2GP
Registration Policy
Temporary Services
Sick/Fit Note
Texting Service
Vaccinations
You & Your Health
COVID-19 Support
Health Review Forms
Asthma Review Form
Alcohol Consumption Review Form
Blood Pressure Review Form
Breathlessness Review Form
Epilepsy Review Form
Male Urinary Tract (IPSS) Review Form
Mental Health Review (PHQ-9) Form
Smoking Review Form
Travel Risk Assessment Form
Help & Support
Oxford hip and knee scores
Keep us up to Date
Change of Contact Details Form
Communication Consent Form
Register as a Carer Form
Register for Online Services Form
Summary Care Record Opt-out Form
Upload photos or documents
Who Do I See?
Private referral for appointment or scan
STAFF ONLY
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Summary Care Record Opt-out Form
Summary Care Record Opt-out Form
Summary Care Record Opt-Out
Section A – Patient’s Details
First Name
*
Last Name
*
Email
*
Enter Email
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*
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Date of birth
*
Please use format day/month/year e.g. 12/05/1979
Phone Number
*
Address
*
Address
Address
Address
Town/City
Town/City
County
County
Postcode
Postcode
Country
Afghanistan
Aland Islands
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antarctica
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bonaire, Sint Eustatius and Saba
Bosnia and Herzegovina
Botswana
Bouvet Island
Brazil
British Indian Ocean Territory
Brunei
Bulgaria
Burkina Faso
Burundi
Côte d'Ivoire
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Croatia
Cuba
Curacao
Cyprus
Czech Republic
Denmark
Djibouti
Dominica
Dominican Republic
East Timor
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands (Malvinas)
Faroe Islands
Fiji
Finland
France
French Guiana
French Polynesia
French Southern Territories
Gabon
Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Heard Island and McDonald Islands
Holy See
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Isle of Man
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macao
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
North Korea
Northern Mariana Islands
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn
Poland
Portugal
Puerto Rico
Qatar
Reunion
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena, Ascension and Tristan da Cunha
Saint Kitts and Nevis
Saint Lucia
Saint Martin (French part)
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Sint Maarten (Dutch part)
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
South Georgia and the South Sandwich Islands
South Korea
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard and Jan Mayen
Swaziland
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Trinidad and Tobago
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
United States Minor Outlying Islands
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
Virgin Islands, British
Virgin Islands, U.S.
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Country
NHS Number
Are you completing this form on behalf of another person or child?
*
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Section B – Complete this section of you are completing the form on behalf of another person or child
Your full name
*
Relationship to patient
*
Signature
Your Signature
*
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Date of signature
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Privacy Policy
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 our
Privacy Policy
to discover how we protect and manage your submitted data.
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