New Patient Registration

Title

Surname

First names

Any previous surnames (if applicable)

Date of Birth

Are you:

Town & Country of birth

NHS Number(if known)

Home Address

Postcode

Home telephone number

Work telephone number

Mobile Number

Email address

Please help us trace your previous medical records by providing the following information

Previous address in the UK (if applicable):

Postcode

Name of previous doctor

Address of previous doctor

If you are from abroad

Your first UK address where you registered with a GP if you were previously living abroad

Postcode

If previously a resident in the UK, date of leaving

Date you first came to live in the UK (if applicable)

If you are returning from the Armed Forces

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:

Address before enlisting

Postcode

Service or Personnel Number

Enlistment date

Date left Armed Forces

If you need your doctor to dispense medicines and appliances*

* Not all doctors are authorised to dispense medicines

Do you live more than 1.6km in a straight line from the nearest chemist

Would you have serious difficulty in getting them from a chemist

What is your ethnic group

Select the option that best describes your ethnic group or background from the options below

White:

British

Irish

Irish Traveller

Traveller

Gypsy/Romany

Polish

Any other white background

Mixed:

White and Black Caribbean

White and Black African

White and Asian

Any other Mixed background

Asian or Asian British:

Indian

Pakistani

Bangladeshi

Any other Asian background

Black or Black British:

Caribbean

African

Somali

Nigerian

Any other Black background

Other ethnic group

Chinese

Filipino

Any other ethnic group

Would prefer not to state

PATIENT DECLARATION for all patients who are not ordinarily 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.

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.

NON-UK EUROPEAN HEALTH INSURANCE CARD (EHIC), PROVISIONAL REPLACEMENT CERTIFICATE (PRC) DETAILS and S1 FORMS

Complete this section if you live in another EEA country, or have moved to the UK to study or retire, or if you live in the UK but work in another EEA member state. Do not complete this section if you have an EHIC issued by the UK.

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.

Do you have a non-UK EHIC or PRC?

If yes, please enter 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

PRC validity period from

PRC validity period to

Do you have an S1 (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.

Information About You

Height

Weight

Your first language

Do you need an interpreter

Medical Information

Please list any serious illnesses / operations / accidents / disabilities / for women any pregnancy related problems and the year they took place / started

Have you ever suffered from any of the following:

Asthma