New Patient Registration

Patient's Details

Please specify: *

Surname: *

Previous Surnames:

First Name(s) *

Gender *

Male

Female

Indeterminate

NHS Number:

How to find my NHS number

Town and Country of birth: *

Home Address: *

If we find after registration that the address given is not your home address, we will not be able to offer a visit and removal from our practice list will be immediate.

Postcode: *

Home Phone Number:

Mobile Phone Number: *

Work/Daytime Phone Number:

You are able to book and cancel some appointments on line, order repeat medication and view your detailed coded record. Please give your email address above if you would like this facility set up and we will email your registration details to you.

We are now using text messages and emails to contact patients, this includes appointment reminders, test results, messages relating to our specific health needs (e.g. flu vaccination reminder), general health information that could benefit you, information about emergencies. Would you please indicate whether you are willing to be contacted in this manner below.

Can we contact you by text?

Yes

No

Can we contact you by email?

Yes

No

Do you have any special communication issues or require any reasonable adjustments?

Yes

No

Please specify:

Are you happy for this to be shared with other organisations in the NHS and Social Care that will be involved in your care?

Yes

No

Do you have a health passport?

Yes

No

Please provide the health passport to our Reception Team so we can take a photocopy for your patient records.

Ethnicity

What is your ethnic group? *

Which one best describes your White background? *

British

Irish

Irish Traveller or Gypsy

Any other White background

Which one best describes your Mixed background? *

White and Black Caribbean

White and Black African

White and Asian

Any other mixed background

Which one best describes your Asian or Asian British background? *

Which one best describes your Black or Black British background? *

African

Caribbean

Any other Black background

Which best describes your other ethnic group background? *

Arab

Any other ethnic group

Do you speak English?

Yes

No

Do you read English?

Yes

No

First Language: *

Emergency Contact

Full Name: *

Relationship to you: *

Phone Number: *

Address: *

Are they your next of kin? *

Yes

No

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

Yes

No

Next of Kin

Please note this information is for emergency use only and will not be given to a third party

Full Name: *

Relationship to you: *

Phone Number: *

Address: *

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

Yes

No

Patient Participation Group

We would like to contact patients occasionally to ask them about the services we provide and their levels of satisfaction. If you would like to have a say in how your surgery is run please select below how you would prefer to be contacted and involved:

Email

Post

Group meetings

No thank you

Allergies

Do you have any allergies?

Yes

No

Please specify what you are allergic to, what happens and when you had your first reaction:

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

Are you from abroad and registering with the NHS for the first time in the UK? *

Yes

No

Date you came to live in the UK: *

Please use this date format: DD/MM/YYYY.

If you are returning from abroad

Previously been registered with the NHS in the UK

Date you left the UK:

Please use this date format: DD/MM/YYYY.

Date you returned to the UK:

Please use this date format: DD/MM/YYYY.

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:

5. Date of Birth:

6. Personal Identification Number:

7. Identification number of the institution:

8. Identification number of the card:

9. Expiry Date:

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

Name of carer:

Phone Number:

Relationship to carer:

E.g. Mother

Address:

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

Yes

No

Are you the carer of an elderly, disabled or chronically ill person?

Yes

No

Who do you care for?

Relationship to person you care for:

Tell us whether you accept cookies

Patient's Details

Ethnicity

Emergency Contact

Next of Kin

Patient Participation Group

Allergies

Previous Details

If you are from abroad

If you are returning from abroad

Supplementary Questions

Ordinarily Resident

European Economic Area (EEA) Country

EHIC/PRC

S1 Form

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

Carers

Hay Fever