CQC Rating Good

New Patient Registration

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16 Years and over

Are you aged 16 years and over: *

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Patient's Details

Information we need to register you with the practice
Please note all fields marked with a * are mandatory for your registration

Title: *

Gender: *

Are you happy for us to contact you by letter? : *

Are you happy for us to contact you by text message? : *

Are you happy for us to contact you by email?: *

Can you speak/ understand English?: *

Can you read English: *

Do you require an interpreter?: *

Ethnicity: *

Previous Details

Please include postcode

Are you registering for the first time in the UK? : *

Are you returning from abroad?: *

If you are from abroad

Please use this date format: DD/MM/YYYY

Refugee: *

Asylum Seeker: *

Are you returning from abroad? : *

If you are returning from abroad

Previously been registered with the NHS in the UK

Please use this date format: DD/MM/YYYY

Were you ever registered with an Armed Forces GP

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:

Footnote: These questions are optional and your answers will not affect your entitlement to register or receive services from the NHS but may improve access to some NHS priority and service charities services

Supplementary Questions

Please select one of the following statements::

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 at reception. Alternatively for more information go to www.nhs.uk/nhs-services/visiting-or-moving-to-england

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.

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?:

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

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.

Please enter the details from your EHIC or PRC below.

S1 Form

Please give your S1 form to the practice staff.

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.

Homelessness

Are you Homeless?:

Do you have an Advocate?:

This is someone who is able to contact you when the practice wants to communicate if you do not have a contact number yourself

Do you consent for the practice to send letters to this address:

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Parent Details

Parent one

Address: *

Are you registered at this practice?: *

Do you require any assistance when communicating with the practice?:

For example: Do you require British Sign Language interpreter, Large print or easy to read form/leaflets?

Can you speak/understand English:

Can you read English:

Do you need an interpreter:

Parent Two

Address:

Are you registered at this practice?:

Do you require any assistance when communicating with the practice?:

For example: Do you require British Sign Language interpreter, Large print or easy to read form/leaflets?

Can you speak/understand English:

Can you read English:

Do you need an interpreter:

Who is the PRIMARY carer?: *

Who has parental responsibility?: *

Next of Kin and Emergency Contact

Next of Kin

NOK Do you give us permission to discuss your medical records with them?:

Emergency Contact

Is your emergency contact the same as Next of Kin?:

Emergency contact Do you give us permission to discuss your medical records with them?:

Carers

Do you have a carer?: *

Are you a carer for someone?: *

Is your child a carer?: *

Does your child have a carer?: *

Do you give us permission to discuss medical record with the carer?: *

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Accessibility to the practice

Do you have a hearing impairment?:

Do you lip-read or use a hearing aid or other communication tool?

Does your child have a hearing impairment?:

Does your child lip-read or use a hearing aid or other communication tool?

Do you have a visual impairment?:

Do you need information in another format, for example Large print or easy to read?

Does your child have a visual impairment?:

Does your child need information in another format, for example Large print or easy to read?

How would you prefer us to communicate with you:

We will try to adhere to your preference

Are you housebound:

You are unable to go out of your house?

Is your child housebound?:

Walking sticks, zimmer frame, wheelchair etc.

Care/residential care home

Is there a 'Coordinate my care' plan in place?:

DNAR in place:

Barthel Index

Feeding ability:

Bathing:

Grooming:

Dressing:

Bowels:

Bladder:

Toilet Use:

Transfers (bed to chair and back):

Mobility (on level surfaces):

Stairs:

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Summary Care Record

Summary Care Record (SCR)

The Summary Care Record (SCR) system is designed to help both your GP and any emergency staff you contact when the surgery is closed to treat your health needs more efficiently.

Your information will be shared between your GP practice, our local hospital and Out Of Hours service. This will enable your GP surgery to access results and any visits you have at the hospital quickly and efficiently, but it also means that if you have an emergency and contact the Out Of Hours service or visit A&E they will have access to your current medications as well as allergies and are better able to treat you.

SCR Options: *

If you do not return this form, a Summary Care Record will be created for you based on implied consent

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NHS Organ Donor registration

For more information on organ donation please visit: www.organdonation.nhs.uk

NHS Blood Donor registration

If you would like to join the NHS Blood Donor Register as someone who may be contacted and would be prepared to donate blood, please visit their website on: www.blood.co.uk or call direct on 03001232323

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.

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Identification Upload

Patient Identification

To fully register you at the practice, we need Two forms of Acceptable ID (if not possible, please let us know).

We will not store these documents and we will securely delete / destroy them after our initial verification.

OPTIONAL: Photo of your face to add to your records to help us identify you (if you agree)

Acceptable Identification: Photo Driving License, Passport, Tenancy agreement, Mortgage statement, Bank statement, Utility bill (date within the past 3 months) etc.

Only following file extensions are allowed: jpg, jpeg, png, webp, pdf, doc, docx, pptx

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Declaration

Privacy Consent

This form collects personal and medical information about you. We use this information to allow the practice team to contact you. Please read our Privacy Policy to discover how we protect and manage your submitted data.

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New Patient Registration

Summary Care Record (SCR)

Patient Identification

Privacy Consent

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