Eston Surgery - New Patient Questionnaire

We advise that you read the following text closely and document your agreement to this patient contract with your signature. Should you feel unable to agree to our surgery policies, we recommend you choose an alternative GP practice

Benzodiazepines and Z-Drugs Please be aware that this surgery does not prescribe long term Benzodiazepines or Z-drugs such as: **Zopiclone,Temazepam, Zolpidem, Nitrazepam, Lorazepam and Diazepam All new patients (non- palliative) who have previously had long term prescriptions for this type of benzodiazepine or sleeping tablet will be immediately started on a reduction program as these medications are only licensed for short term prescribing.

High Dose Opiates and Gabapentinoids Any non-palliative patients joining the surgery requesting high doses of addictive opioids such as Tramadol or Morphine will be given an appointment with our pharmacist for review to ensure the prescribing is within license, has clinical indication is appropriate and may be given assistance with step down reduction plans, change of medication, specialist advice or referred to specialist services. Requests for Gabapentin/Pregabalin from new patients will only be considered with evidence from your previous practice and a valid clinical indication for this type of Gabapentinoid medication and dose to be prescribed

Violence and Aggression - We are here to help you, thank you for treating us with respect. We operate a zero-tolerance policy towards violence and aggression, this includes shouting and swearing at our team. Any patient who behaves in a fashion that can be classed as aggressive, abusive or violent towards any member of staff or another patient on or around our premises will be instantly removed from our list and reported to the police.

Appointments - The reception staff will ask you for some details regarding your issue. This is confidential and important so the reception team can navigate you to the best person to see. Urgent or same day appointments are not for sick notes or lost prescriptions. Abuse of the appointment system will result a warning which could result in removal from our list.

Failure To Attend -Should you fail to attend for an appointment you will receive our standard text reminding you of this agreement, after 3rd failed appointments, you could be removed from the practice list without further notice. Thank you for your support in aiding and maintaining a good patient / practice relationship,

Do you agree that you may be contacted from time to time, via SMS, with important health information, appointment reminders., care plans, information to help you manage your condition , invites and important information about the practice ( SMS is not used for marketing purposes) *

Yes No

Would you like to join our Online Patient Reference Group whom we consult from time to time about services ( entering your email as consent )

Do you want to register for on-line appointment booking and prescription ordering services? ( consent to receive SMS messages is required) *

Yes No

Which Pharmacy would you like your prescriptions to be sent to? *

Information about your health and care helps the NHS to improve your individual care, speed up diagnosis, plan your local services and research new treatments. Do you consent to sharing your health records with other healthcare organisations? *

Yes No

Eston Surgery - New Patient Questionnaire

Eston Surgery - New Patient Questionnaire

Further Information