New Patient Registration (Over 16)

Patient's Details

Please specify:

Surname: *

Previous Surnames:

First Name(s) *

Sex *

Male

Female

Indeterminate

NHS Number:

Town and Country of birth: *

Full Home Address: *

Postcode: *

Primary Contact Number: *

Secondary Contact Number:

Please select your preferred choice of contact:

Text

Phone

Email

Post

Do you live in a residential/nursing home?

Yes

No

Occupation:

Religion:

Service Families and Military Veterans

As a practice, we fully support the Armed Forces Covenant. We can only do this if we know our patients connections to the Armed Forces. Please select all that apply to you:

I am a Military Veteran

I am currently serving in the Reserve Forces

I am married/civil partnership to a serving member of the Regular/Reserve Armed Forces

I am married/civil partnership to a Military Veteran

I am under 18 and my parent(s) are serving member(s) of the armed forces

I am under 18 and my parent(s) are veteran(s) of the armed forces

Ethnicity

Please state:

Language

Main Language:

Do you speak English?

Yes

No

Do you read English?

Yes

No

Previous Details

Previous address in UK: *

Please include postcode.

Name and address of previous GP: *

If you are from abroad

Registering with the NHS for the first time in the UK

If you are returning from abroad

Previously been registered with the NHS in the UK

Supplementary Questions

I am not ordinarily a resident in the UK

Ordinarily Resident

Anybody in England can register with a GP practice and receive free medical care from that practice.

However, if you are not ‘ordinarily resident’ in the UK you may have to pay for NHS treatment outside of the GP practice. Being ordinarily resident broadly means living lawfully in the UK on a properly settled basis for the time being. In most cases, nationals of countries outside the European Economic Area must also have the status of ‘indefinite leave to remain’ in the UK.

Some services, such as diagnostic tests of suspected infectious diseases and any treatment of those diseases are free of charge to all people, while some groups who are not ordinarily resident here are exempt from all treatment charges.

More information on ordinary residence, exemptions and paying for NHS services can be found in the Visitor and Migrant patient leaflet, available from your GP practice. Alternatively for more information go to www.nhs.uk/visitingengland.

You may be asked to provide proof of entitlement in order to receive free NHS treatment outside of the GP practice, otherwise you may be charged for your treatment. Even if you have to pay for a service, you will always be provided with any immediately necessary or urgent treatment, regardless of advance payment.

The information you give on this form will be used to assist in identifying your chargeable status, and may be shared, including with NHS secondary care organisations (e.g. hospitals) and NHS Digital, for the purposes of validation, invoicing and cost recovery. You may be contacted on behalf of the NHS to confirm any details you have provided.

Please select one of the following statements:

I understand that I may need to pay for NHS treatment outside of the GP practice

I understand I have a valid exemption from paying for NHS treatment outside of the GP practice. This includes for example, an EHIC, or payment of the Immigration Health Charge (“the Surcharge”), when accompanied by a valid visa. I can provide documents to support this when requested

I do not know my chargeable status

I declare that the information I give on this form is correct and complete. I understand that if it is not correct, appropriate
action may be taken against me.

A parent/guardian should complete the form on behalf of a child under 16.

Signature: *

Print Name:

On behalf of:

Relationship to patient:

Date:

European Economic Area (EEA) Country

For a list of EEA countries visit: www.gov.uk/eu-eea

Do you live in another EEA country, or have moved to the UK to study or retire, or live in the UK but work in another EEA member state?

Yes

No

Do you have a non-UK European Health Insurance Card (EHIC) or a Provisional Replacement Certificate (PRC) ?

Yes

No

If you are visiting from another EEA country and do not hold a current EHIC (or Provisional Replacement Certificate (PRC))/S1, you may be billed for the cost of any treatment received outside of the GP practice, including at a hospital.

EHIC/PRC

Please enter the details from your EHIC or PRC below.

Country Code:

3. Name:

4. Given Names:

6. Personal Identification Number:

7. Identification number of the institution:

8. Identification number of the card:

PRC validity period - from:

PRC validity period - to:

S1 Form

Do you have an S1 Form?

I have an S1 form (e.g. you are retiring to the UK or you have been posted here by your employer for work or you live in the UK but work in another EEA member state).

Please give your S1 form to the practice staff.

How will your EHIC/PRC/S1 data be used?

By using your EHIC or PRC for NHS treatment costs your EHIC or PRC data and GP appointment data will be shared with NHS secondary care (hospitals) and NHS Digital solely for the purposes of cost recovery. Your clinical data will not be shared in the cost recovery process.

Your EHIC, PRC or S1 information will be shared with The Department for Work and Pensions for the purpose of recovering your NHS costs from your home country.

Carers

Do you have a carer?

Yes

No

Are you a carer for someone?

Yes

No

Name of carer:

Phone Number:

Address:

Do you give us permission to discuss your medical record with your carer?

Yes

No

Is your carer a patient at the surgery?

Yes

No

Emergency Contact / Next of Kin

Full Name:

Relationship to you:

Phone Number:

Are they your next of kin?

Yes

No

Do you give us permission to discuss your medical records with them?

Yes

No

Contacting You

We will use your contact details to send reminders about appointments, reviews and other services which may be of benefit in your medical care.

Do you consent to the Surgery sending letters to your home address?

Yes

No

Do you consent to the Surgery sending text messages to your mobile?

Yes

No

Do you consent to the Surgery sending messages to you by email?

Yes

No

Do you consent to the Surgery leaving messages on your phone?

Yes

No

(We will not leave detailed messages on your phone, but may ask you to contact us or leave a simple message if we do not need to speak to you)

Are you interested in joining our Patient Participation Group (PPG)?

Yes

No

Summary Care Record

Your Summary Care Record is a short summary of your GP medical records. It tells other health and care staff who care for you about the medicines you take and your allergies.

This means they can give you better care if you need health care away from your usual doctor's surgery, for instance in A&E or when you're on holiday.

If you agree, we will include additional information in your Summary Care Record. This will help you get better care when you are away from the GP practice.

Consent *

I agree to having additional information in my Summary Care Record

I do not want additional information in my Summary Care Record

Are you sure? If you do not allow us to include additional information in your Summary Care Record, your care may be harmed if you get seriously ill.

NHS Organ Donor registration

For more information on organ donation please visit: www.organdonation.nhs.uk

NHS Blood Donor registration

If you would like to join the NHS Blood Donor Register as someone who may be contacted and would be prepared to donate blood, please visit their website on: www.blood.co.uk or call direct on 03001232323

Resuscitation wishes and Power of Attorney

Do you have a DNACPR (Do not attempt CPR) form in place?

Yes

No

Please provide details of who holds this and where (and upload a copy to this form):

Does anybody hold Lasting Power of Attorney for Health and Welfare for you?

Yes

No