Your DetailsYour Name* Organisation Name*Organisation Address* Street Address Address Line 2 City ZIP / Postal Code Telephone Number*Email Address* Enter Email Confirm Email Practice InformationPractice Managers Name* Senior Partner* Number of Partners*Please enter a value between 1 and 999.Privacy Officer* This is a nominated person responsible for monitoring the record viewing activity of their users. This person will be given the access rights on their Smartcard to manage alerts and audit record viewing activity.Privacy Officer Staff Role* This will be the staff role as stated on the smartcard.Main Contact* Second Contact* Practice ID / Site Reference*This will be your practice's national ID code. E.G. E12345Do you have a branch site?*YesNoBranch site address* Street Address Address Line 2 City ZIP / Postal Code Do you have another branch site?*YesNoBranch site address* Street Address Address Line 2 City ZIP / Postal Code Do you have any more branch sites?*YesNoAddresses* Migration QuestionsCurrent Capitation*Current System Type*Please selectEMIS LVEMIS PCSEMIS WEBSynergyVisionMicrotestHealthysoftOtherPlease specify*Is your data hosted?*YesNoScanning software*Please selectNoneApolloScanApolloScan 2DocmanCorrespondence ManagerOtherPlease specify*Do you currently dispense?*YesNoDo you want your dispensary stock migrating?*YesNoWhat tape type do you use to backup your clinical data?*HP Ultrium LTO1HP Ultrium LTO2HP Ultrium LTO3HP Ultrium LTO4HP Ultrium LTO5Quantum DLTQuantum DLT1OtherWhat backup software do you use?*Backup ExecNT BackupPlease Specify*Please supply any Health Authorities that you are linked with.* Please supply any Pathology labs that you are linked with.* Do you provide any services other than GP or have any special registration types?*For example, walk in patient, drug dependency..RBAC All end users need to have a role profile added to their Smart Cards by the RA agent. This will ensure that end users have the correct access rights to perform their role within SystmOne. It is essential that the access rights allocated to the Smart Card reflect the true rights required in SystmOne, otherwise end users will not be able to access the correct SystmOne functions. You need to make sure that you have your Smart cards set up correctly and they are ready to use for Go Live. If you have any problems with the set up you will need to speak to your RA manager.Are you an existing GP2GP enabled practice?*YesNoAre you an existing ETP2 enabled practice?*YesNoWould you like ETP2 to be enabled for Go Live on SystmOne?*YesNoAre you an existing Summary Care Record enabled practice?*YesNoHave you performed the initial upload to spine?*YesNoWould like 'Permission to view' enabled?*YesNoThis must be confirmed with your SCR implementation managerDo you want to be enabled to receive 111 messages via ITK?*YesNoPlease request your service ID from your DoS lead prior to Go Live.Do you wish to be enabled for VDI (Virtual Desktop Infrastructure)?*YesNoIf yes, you must send a request to our VDI mailbox (VDI.firstname.lastname@example.org or VDI.email@example.com) in order for this to be setup* Request sent Do you want to be enabled for sharing prior to go live?*YesNo Please be aware that this can be turned on after go live if required, but this functionality cannot be turned off once enabled.Do you wish to opt-in to ResearchOne?*YesNoYou can find more information at www.researchone.org. Contribute anonymous aggregated information to Public Health England's national symptom surveillance system?*YesNoYou can read more about this at http://www.tpp-uk.com/files/2013/07/PHE-TPP-Primary-Care-Surveillance_V3.pdfPotential Go Live Date*Day12345678910111213141516171819202122232425262728293031Month123456789101112Year2019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920The average migration is around 8-12 weeks. Please consider this when selecting a date.We would like to capture some information pre-deployment to measure how SystmOne will improve and enhance the way your practice works. If you and your colleagues complete our short surveys, you will be in with a chance of winning a Brother label printer! Completing the surveys should take around 1-2 minutes. If you would like to opt out, please tick the box below.*I do not wish to be contactedCommentsThis field is for validation purposes and should be left unchanged.