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

Title

First Name

Surname

Previous Surname

Date of Birth

Sex

Birth Town

Birth Country

Address

Postcode

Home Number

Mobile Number

Email Address

I am a student at:

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

NHS Number

IF PREVIOUSLY RESIDENT IN UK, DATE OF LEAVING

DATE YOU FIRST CAME TO LIVE IN UK

YOUR PREVIOUS ADDRESS IN UK

NAME OF PREVIOUS GP WHILE AT PREVIOUS ADDRESS

ADDRESS OF PREVIOUS DOCTOR

Information About You

What is your height?

What is your weight?

What is your first language?

Do you need an interpreter?

Ethnic Group

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).

Do you have a non-UK EHIC or PRC?

If yes, please enter details from your EHIC or PRC below:

Country Code:

Name on EHIC:

Given Names:

Date of Birth

Personal Identification Number:

Identification number of the institution:

Identification number of the card:

Expiry Date:

PRC validity period

a) From:

b) 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). Please give your S1 form to the practice staff.

IF YOU ARE RETURNING FROM THE ARMED FORCES

Address before enlisting

Service/Personnel No.

Enlistment date

COMPLETE YOUR CHILD'S REGISTRATION

If you are registering a child under 5

I wish the child above to be registered with the named doctor for Child Health Surveillance

If you need your doctor to dispense medicines and appliances

Signature on behalf of patient

Date

Carers

Do you have a carer?

If yes please give details

Are you a carer?

(If yes please give details)

Women

Have you ever had a cervical smear?

If 'yes', please state when, where and the result

Will

Do you hold a Living Will?

Smoking

Do you smoke?

If 'No', have you ever smoked?

If you do currently smoke, how many cigarettes or ounces of tobacco do you smoke per week?

Would you like advice on giving up smoking?

Alcohol

MEN: How often do you have EIGHT or more drinks on one occasion? WOMEN: How often do you have SIX or more drinks on one occasion?

How often during the last year have you failed to do what was normally expected of you because of drinking?

In the last year has a relative or friend, or a doctor or other health worker been concerned about your drinking or suggested you cut down?

Family History

Please state any serious illness, in particular cancer, heart disease, stroke, high blood pressure, diabetes or any inherited disease. Please state your relationship to the individual and in the case of cancer, the type of cancer. *

Next of Kin

Please give name, address, telephone number and relationship of next of kin

For patients aged 65 and over or those with a chronic disease (e.g. asthma or diabetes)

Have you had a flu vaccination? Enter date or 'never':

Have you had a pneumococcal vaccination? Enter date or 'never'

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,

Please select one of the following boxes:

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.

Are you a parent or guardian, filling out this form on behalf of a child under 16?

Name parent or guardian

Relationship to patient:

Signed

Date

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

Signature confirming consent to organ donation

Date

NHS BLOOD DONOR REGISTRATION

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

I would like to join the NHS Blood Donor Register as someone who may be contacted and would be prepared to donate blood.

Have you have given blood in the last 3 years

Signature confirming consent to inclusion on the NHS Blood Donor Register

Date

Preferred address for donation: (if different from above, e.g. place of work)

Postcode

Contacting You

Do you agree that you may be contacted from time to time, via email and/or SMS, with practice news, advice about my health and/or appointment reminders.

Signature

Date

Proof of Identity and Address Provided

You will need to provide a copy of at least two of the documents listed below before your registration can be processed. You can email a copy to wimbledon.villagesurgery@nhs.net

Birth Certificate

Driving Licence

Passport

Utility Bill

Allowance Book

Solicitors Letter

Offer of Tenancy

Other

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.

I consent to my information being used for the purposes described above and wish to submit this online form to Wimbledon Village Surgery • 35a High Street , Wimbledon, SW19 5BY.

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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Key Information

New Patient Questionnaire & Registration Form

Privacy Protection