New Patient Registration

Proof of Indentification

To complete this form you will need to upload 2 forms of identification, one of which must include a photograph. For example a picture of your photo driving licence and a recent utility bill.

Please upload your first identification file (accepted files .jpg .png) *

Please upload your second identification file (accepted files .jpg .png) *

Ethnicity

Emergency Contact

Full Name:

Relationship to you:

Phone Number:

Are they your Next of Kin? No Yes

Do you give us permission to discuss your medical records with them? No Yes

Allergies

Do you have any allergies? No Yes

Communication Needs

Do you have any special communication needs? No Yes

If yes, please select: Sign Language Large Print Other

Previous Details

Previous address in UK (please include postcode):

Name and address of previous GP:

Where did you last receive treatment? (i.e GP, Walk-in Centre, MIU, Emergency Dept etc):

Date of last treatment:

What was the outcome of this visit? (i.e prescription):

If you are from abroad (Registering for the first time in the UK)

Date you came to live in the UK:

If you are returning from abroad (previously been a resident in the UK)

Date you left the UK:

Date you returned to the UK:

Carers

Do you have a carer? No Yes

Are you a carer for someone? No Yes

Lifestyle

Height:

Weight:

Do you exercise? No Yes

Smoking Status: Current Smoker Ex Smoker Never Smoked

Adult Females only

Are you currently, or think you may be, pregnant? No Yes

Do you have any children? No Yes

Which method of contraception (if any) are you using at present?

When was your last cervical smear?

What was the result of the cervical smear?

Immunisation History

Medical History

Major Illnesses (please include dates):

Past Operations (please include dates):

Have any close relatives (father, mother, sister, brother only) ever suffered from any of the following:

Heart attack

Stroke

Diabetes

High blood pressure

Asthma

Glaucoma

Cancer

Current Medication and dosage:

What happens to my information?

Personal and medical information about patients registered at this practice are primarily kept electronically, although some is kept in paper form. Some information will be sent to hospital consultants and other health professionals to whom you are referred by your GP in order to provide continued healthcare and obtain treatment for you.

We sometimes use accredited suppliers for our communication with you, for example when we send recall letters for review clinics or medication reviews. All suppliers we use are checked carefully to ensure they comply with strict confidentiality protocols.

To ensure the security of all patient information, all staff that has access to your records is covered by confidentiality clauses in their contracts and the Data Protection Act and the Freedom of Information Act. Our guiding principle is that we hold your records in strict confidence.

I certify that the information I have provided is correct and consent to my personal and medical information being used as stated above.

Signature: *

Date: *

NHS Organ Donor registration

If you wish your medical records to be marked that you are willing to donate organs/tissue for transplantation after your death:

Kidneys

Heart

Liver

Corneas

Lungs

Pancreas

Any part of my body

Any part of my organs or tissues

Signature:

Date:

If you would like to join the NHS Organ Donation Register please visit their website on: www.organdonation.nhs.uk

Supplementary Questions

Ordinarily Resident

I am not ordinarily a resident in the UK

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? No Yes

Do you have a non-UK European Health Insurance Card (EHIC) or a Provisional Replacement Certificate (PRC)? No Yes

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:

Name:

Given Names:

Date of Birth:

Personal Identification Number:

Identification number of the Institution:

Identification number of the card:

Expiry Date:

EPRC validity period: From: 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).

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.

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