New Patient Registration Form

Patient's Details

Title MrMrsMissMs

Surname

First Name

Previous Surname

Town and Country of Birth

Telephone Number

Date of Birth

NHS No. (if known)

Sex MaleFemale

Home Address Line 1

Home Address Line 2

Postcode

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

Your previous address in the UK

Name of previous GP while at previous address

Address of that Doctor

If you are from abroad

Your first UK address where registered with a GP

If previously resident in UK, date of leaving

Date you first came to live in UK

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:
n/aRegularReservistVeteranFamily Member (Spouse, Civil Partner, Service Child)

Address before enlisting

Postcode

Service or Personnel number

Enlistment date

Discharge date (if applicable)

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.

If you need your doctor to dispense medicines and appliances*

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

I would have serious difficulty in getting them from a chemist

*Not all doctors are authorised to dispense medicines

Signatures

Please select only one option:

Signature Signature of PatientSignature on behalf of patient

If Signature of Patient selected, please type your full name here

If Signature on behalf of Patient selected, please type your full name here

Date of Signature

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. Please tick the boxes that apply.

Any of my organs and tissue

Kidneys
Heart
Liver
Corneas
Lungs
Pancreas

Signature confirming my consent to join the NHS Organ Donor Register

Please type full name

Date of Signature for Organ Donor

NHS Blood Donor registration

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

Tick here if you have given blood in the last 3 years

Signature confirming my consent to join the NHS Blood Donor Register

Please type full name here

Date

My preferred address for donation is: (only if different from above, e.g. your place of work)

Postcode

PATIENT DECLARATION for all patients who are not ordinarily resident in the UK

These questions are optional and your answers will not affect your entitlement to register or receive services from your GP.

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 tick one of the following boxes:

a) I understand that I may need to pay for NHS treatment outside of the GP practice
b) 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
c) I do not know my chargeable status

A parent/guardian should complete the form on behalf of a child under 16.

Signed (please type surname)

Full Name

On Behalf of name:

Date

Relationship to patient

Non-UK European Health Insurance Card (EHIC)

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? n/aNoYes

Country Code

Name

Given Name

Date of Birth

Personal Identification Number

Identification number of the institution

Identification number of the card

Expiry Date

PRC validity period (a) From:

PRC validity period (a) To:

Please tick if 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

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.

Your email address to receive a copy of the completed form

This is for your benefit and is not included on the form sent to the surgery

Your Email (required)