New Patient Questionnaire & Registration Form

Please allow at least 15 minutes to complete the form.

Due to a change of policy, we are pleased to announce that this medical practice now warmly welcomes new patients who reside anywhere locally, with no catchment area limitations.

As a new patient wishing to register with this medical practice, you will be asked to complete a registration form and brief questionnaire outlining your medical history.

Your NHS number is not essential but bringing your previous NHS registration card along when registering will expedite the process. Do not worry if you cannot find your NHS number as we can trace these electronically.

One item of photographic ID is also required to complete the registration process, such as a passport or photographic driving licence.

(Please be aware that sending this form will NOT automatically register you with the surgery. We will need proof of ID and address before we are able to process the registration application.)

Your Contact Details
Please help us trace your previous medical records by providing the following
PLEASE PROVIDE THIS INFORMATION TO HELP US IDENTIFY YOUR NEEDS
Medical Information
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 the GP practice, including at hospital).

Are returning from the Armed Forces
Carers
Women
Will
Smoking
Alcohol
Family History
Next of Kin
For patients aged 65 and over or those with a chronic disease (e.g. asthma or diabetes)
SUPPLEMENTARY QUESTIONS | 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,

NHS ORGAN DONOR REGISTRATION

I want to register my details on the NHS Organ Donor Register as someone whose organs/tissue may be used for transplantation after my death. For more information, please ask for the leaflet on joining the NHS Organ Donor Register

NHS BLOOD DONOR REGISTRATION

For more information, please ask for the leaflet on joining the NHS Blood Donor Register

Contacting You
Signature
Proof of Identity and Address Provided
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.


Privacy Protection

Information submitted through secure forms is used only for the purposes of processing your request. We may be in touch with you in relation to the information submitted.

All Information submitted through secure forms is secured with a private key and is accessed over a secure connection by nominated staff. We have a strict confidentiality policy.

This information is not shared with any third party organisations.

This information is retained for up to 28 days.

Learn more about our Privacy Policy and Terms of Use. Should you have any concerns about sending your personal details using the web, please use one of the alternative methods offered by our organisation.


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