New Patient Registration

Practice Boundary

To register as a new patient, you will need to live within our practice boundary.

*

I confirm I have checked and live within the practice boundary

Have you been registered with this surgery before?

Yes

No

Patient's Details

Please specify:

Surname: *

Previous Surnames:

First Name(s) *

Sex *

Male

Female

Indeterminate

NHS Number:

Town and Country of birth: *

Home Address: *

Postcode: *

Occupation:

Marital Status:

By supplying us with an email address you consent to us sending you any correspondence in the future via email.

Home Phone Number:

Mobile Phone Number:

Work Phone Number:

Would you like to receive text message appointment reminders and other notices?

Yes

No

Please inform us if your contact details change at any time

Can we contact you by telephone call?

Yes

No

What is your preferred method for us to contact you?

Letter

Text message

Email

Please specify any additional support you require from the practice:

e.g. a British sign language interpreter for every appointment, contact preferences etc.

Housing Status

Ethnicity

Please state:

Do you speak English?

Yes

No

Do you read English?

Yes

No

Is English your first spoken language?

Yes

No

Please state your main spoken language:

Do you require a translator when you visit the surgery?

Yes

No

Emergency Contact

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

Is your Next of Kin registered at this practice?

Yes

No

Next of Kin

Full Name:

Relationship to you:

Phone Number:

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

Yes

No

Is your Next of Kin registered at this practice?

Yes

No

Allergies

Do you have any allergies?

Yes

No

Drug allergies:

Food allergies:

Any other allergies:

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

Date you came to live in the UK:

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

If you are a non-UK resident, please provide your Biometric Residence Permit Number:

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.

Military Veteran

Have you previously served in any of the military services?

Yes

No

Please state the date you were discharged:

Please use this date format: DD/MM/YYYY

Are you content that this is annotated on your medical record?

Yes

No

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/visiting-or-moving-to-england.

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:

Address:

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

Yes

No

Are you a carer for someone?

Yes

No

Are you an informal carer? (do you care for a family member or friend)

Yes

No

Please give details of the person you are caring for (their name, address, postcode and if they are a relation to you):

Do you have a carers booklet?

Yes

No

Tell us whether you accept cookies

Practice Boundary

Patient's Details

Housing Status

Ethnicity

Emergency Contact

Next of Kin

Allergies

Previous Details

If you are from abroad

If you are returning from abroad

Military Veteran

Supplementary Questions

Ordinarily Resident

European Economic Area (EEA) Country

EHIC/PRC

S1 Form

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

Carers

New Patients