New Patient Registration

Boundary Area

Catchment Area

If you would like to register with the practice, please fill in this form. To register as a new patient, you will need to live within our Practice Boundary.

New Patient Registration Form

If you would like to register with the practice, please fill in this form. To register as a new patient you will need to live within our Practice Boundary.

Patient's Details

Name

Prefix First Last

Date of Birth

DD slash MM slash YYYY

Sex

Male

Female

Indeterminate

Date of Birth

DD slash MM slash YYYY

Do you know your NHS number?

Yes

I don’t Have one

NHS Number:

Town and Country of birth:

Address

Street Address Address Line 2 City Postcode

Home Phone Number: Optional

Mobile Phone Number: Optional

Work Phone Number: Optional

Can we contact you by text?

Yes

Can we contact you by email?

Yes

Occupation:

Emergency Contact

Full Name:

Relationship to you:

Phone Number:

Are they your next of kin?

Yes

Previous Details

Do you have a previous address in the UK?

Yes

Previous address in UK:

Please include postcode.

Do you have a previous GP practice in the UK?

Yes

Name and address of previous GP practice:

Ethnicity

What is your ethnic group?

White

Mixed

Asian or Asian British

Black or Black British

Other ethnic group

Do not wish to state

Please select one option that best describes your White ethnic group or background from the options below:

British

Irish

Irish Traveller

Traveller

Gypsy/Romany

Polish

Any other White background

Please select one option that best describes your Mixed ethnic group or background from the options below:

White and Black Caribbean

White and Black African

White and Asian

Any other Mixed background

Please select one option that best describes your Asian or Asian British ethnic group or background from the options below:

Indian

Pakistani

Bangladeshi

Any other Asian or Asian British background

Please select one option that best describes your Black or Black British ethnic group or background from the options below:

Caribbean

African

Somali

Nigerian

Any other Black or Black British background

Please select one option that best describes your other ethnic group or background from the options below:

Chinese

Filipino

Any other ethnic group or background

Please specify your ethnic group or background: Optional

Do you speak English?

Yes

Do you read English?

Yes

First Language:

If you are from abroad

Registering with the NHS for the first time in the UK

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

yes

Date you came to live in the UK:

DD slash MM slash YYYY

If you are returning from abroad

Previously been registered with the NHS in the UK

Are you returning from abroad and have previously been registered with the NHS in the UK?

Yes

Date you left the UK:

DD slash MM slash YYYY

Date you returned to the UK:

DD slash MM slash YYYY

Supplementary Questions

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/nhs-services/visiting-or-moving-to-england.

I am not ordinarily a resident in the UK

Optional

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

DD slash MM slash YYYY

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

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

Yes

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). Optional

Were you ever registered with an Armed Forces GP

Please indicate if you have served in the UK Armed Forces and/or been registered with a Ministry of Defence GP in the UK or overseas:

Regular Optional

Reservist Optional

Veteran Optional

Family Member (Spouse, Civil Partner, Service Child) Optional

Address before enlisting (including postcode): Optional

Service or Personnel number: Optional

Enlistment date: Optional

Discharge date (if applicable): Optional

Special Communication Needs

Do you have any special communication needs?

Yes

Please specify:

Carers

Do you have a carer?

Yes

Are you a carer for someone?

Yes

Name of carer:

Phone Number

Address:

Medical History

Please list any major illnesses you have had:

Please include dates.

Please list any past operations you have had:

Please include dates.

Current medication:

Do you have any significant mobility issues?

Yes

Please specify:

Sight:

Good

Poor

Registered Blind

Hearing:

Good

Poor

Partially Deaf

Deaf

Family History

Please list any family history of illnesses (including the relative and year they were diagnosed):

Allergies

Do you have any allergies?

Yes

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

Alcohol Consumption

How often do you have a drink containing alcohol?

Never

Monthly or less

2-4 times per month

2-3 times per week

4+ times per week

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

1-2

3-4

5-6

7-9

10+

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?

Never

Less than monthly

Monthly

Weekly

Daily or almost daily

Lifestyle

Smoking Status:

Current Smoker

Ex Smoker

Never Smoked

How many do you smoke per day? Optional

Are you interested in advice on how to quit?

Yes

How many did you smoke per day?

When did you stop?

Height:

Weight

Please state how much exercise and what type of exercise you do per week:

Adult Females only

When was your last cervical smear? Optional

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

Was it done at:

A Previous GP Optional

A Family Planning Clinic Optional

What was the result of the cervical smear? Optional

Have you had a hysterectomy?

Yes Optional

No Optional

What type of hysterectomy? Optional

Do you still have your ovaries?

Yes Optional

No Optional

Immunisation History

Please list any immunisations/vaccinations you have had: Optional

Please include dates.

Nominate a Pharmacy

Pharmacy Name: Optional

Pharmacy Address: Optional

Pharmacy Postcode: Optional

Donation Wishes

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

Yes

Have you opted out?

Yes

Do you donate blood?

Yes

Summary Care Record

Please select one of the following options

Yes, I would like a Summary Care Record – Express consent for medication, allergies and adverse reactions only.

Yes, I would like an Enhanced Summary Care Record – Express consent for medication, allergies, adverse reactions and additional information.

No, I would not like a Summary Care Record – Express dissent for Summary Care Record (opt out).

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

Yes

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

Yes

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.

File

Drop files here or

Max. file size: 50 MB.

To help complete your registration, please upload proof of address to ensure you live within our catchment area. This should include your name and address. The registration cannot be processed until these documents have been submitted. If you cannot upload proof of address, please bring this to the surgery in person.

Signature

Date

DD slash MM slash YYYY

Boundary Area

Catchment Area

New Patient Registration Form

New Patient Registration

Patient's Details

Emergency Contact

Previous Details

Ethnicity

If you are from abroad

If you are returning from abroad

Supplementary Questions

European Economic Area (EEA) Country

Please enter the details from your EHIC or PRC below.

S1 Form

Were you ever registered with an Armed Forces GP

Special Communication Needs

Carers

Medical History

Family History

Allergies

Alcohol Consumption

Lifestyle

Adult Females only

Immunisation History

Nominate a Pharmacy

Donation Wishes

Summary Care Record

What happens to my information?

Thank you for your feedback.