New Patient Registration

Patient's Details

Please specify:

Surname: *

Previous Surnames:

First Name(s) *

Sex *

Male

Female

Indeterminate

NHS Number:

Town and Country of birth: *

House Name/Flat Number:

Number and Street Address: *

Locality:

Town/City: *

County: *

Postcode: *

Home Phone Number:

Mobile Phone Number:

Work Phone Number:

Can we contact you by text?

Yes

No

Can we contact you by email?

Yes

No

Preferred method of contact:

Text

Phone

Email

Post

Have you ever been registered with this practice before?

Yes

No

Do you live in a residential home?

Yes

No

Previous Details

Previous Address in the UK

House Name/Flat Number:

Number and Street Address:

Locality:

Town/City:

County:

Postcode:

Previous GP Surgery

GP Surgery Name:

Number and Street Address:

Locality:

Town/City:

County:

Postcode:

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 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.

Ethnicity

Please state:

Do you speak English?

Yes

No

Do you read English?

Yes

No

Country of birth:

First Language:

Carers

Do you have a carer?

Yes

No

Are you a carer for someone?

Yes

No

Name of carer:

Date of Birth:

Address:

Telephone:

Mobile:

Relationship to you:

Is this person your main carer?

Yes

No

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

Yes

No

Emergency Contact

Full Name:

Date of Birth:

Address:

Telephone:

Mobile:

Relationship to you:

Is this person registered at the practice as well?

Yes

No

Are they your next of kin?

Yes

No

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

Yes

No

Family Details

Parents/Guardian (please complete for anyone 18 years and under, and/or if your parents are your main carers due to mental or physical disability.

Mother

Other Guardian

Please specify:

Mother is registered with this practice?

Yes

No

Other guardian is registered with this practice?

Yes

No

Name:

Date of Birth:

Address:

Telephone:

Mobile:

Father

Other Guardian

Please Specify:

Father is registered with this practice?

Yes

No

Other guardian is registered with this practice?

Yes

No

Name:

Date of Birth:

Address:

Telephone:

Mobile:

Children (please complete if your children are registered at this practice):

Please include forename, Surname and Date of Birth for each child.

Summary Care Record

If you decide to have a Summary Care Record (SCR), it will contain important information about any medicines you are taking, allergies you suffer from and any bad reactions to medicines that you have had. It will also include basic information about your current diagnoses.

Giving healthcare staff access to this information can prevent mistakes being made when caring for you in an emergency or when your GP practice is closed. Your Summary Care Record will also include your name, address, date of birth and your unique NHS Number to help identify you correctly. If you and your GP decide to include more information it can be added, but only with your express permission.

For more information please call 0300 123 3020 or visit www.nhscarerecords.nhs.uk.

I do not wish to have a Summary Care Record (N.B. This will mean NHS healthcare staff caring for you may not be aware of your current medications, any allergies or reactions to previous medications)

I wish to opt out of SCR

Electronic Prescribing Service (EPS)

The Electronic Prescribing Service (EPS), allows prescribers such as GPs and practice nurses to send prescriptions electronically to a dispenser (such as a pharmacy) of the patient's choice. This makes the prescribing and dispensing process more efficient and convenient for patients and staff. To help achieve this as a practice, we would encourage all patients to opt for electronic prescribing.

I do give consent for my prescriptions to be sent electronically to the pharmacy

I do not give consent for my prescriptions to be sent electronically to the pharmacy

Donation Wishes

Do you have a donor card or are you on the organ donor register?

Yes

No

Do you donate blood?

Yes

No

Resuscitation Wishes and Power of Attorney

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

Yes

No

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

Yes

No

Lifestyle

Height:

Weight:

If you would like advice on managing a healthy weight, please visit https://www.nhs.uk/live-well/ or contact the practice who will be able to direct you to the most appropriate service.

Do you smoke?

Yes

No

How many cigarettes do you smoke daily?

Have you smoked in the past?

Yes

No

How many cigarettes did you used to smoke per day?

Smoking is the UKs single greatest cause of preventable illness.

Stopping smoking is not easy but it can be done, and there is now a comprehensive, NHS Smoking Cessation Service offering support and help to smokers wanting to stop, with cessation aids available on NHS prescription.

If you would like help and advice on how to give up smoking, please contact www.quit4life.nhs.uk or ask at reception.

Alcohol Consumption

This is one unit of alcohol:

Amount of different types of drink representing one unit of alcohol

And each one of these, is more than one unit:

Amount of different types of drink representing more than one unit of alcohol

How often do you have a drink containing alcohol? *

How many units of alcohol do you drink on a typical day when you are drinking? *

How often have you had 6 or more units if female, or 8 or more if male, on a single occasion in the last year? *

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