Registration form with Questionnaire

Fields marked "REQUIRED" are compulsory.. You should only send this form if you are sure that you are eligible to join this practice. Sending this form will NOT automatically register you with the surgery. Sending this form does NOT guarantee or even imply that you will be accepted onto the practice register.

Last Updated: 25/10/2023

Patient Details

Title *

Surname *

First Name *

Date of Birth *

NHS number

Sex *

Male

Female

Previous Surname

Home Address *

Postcode *

Mobile Number

Home Number

E-mail address

Town and country of birth *

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

Your Previous Address *

Name of Previous GP practice *

Address of previous GP practice

If you are from Abroad

Your first UK address when registered with a GP

If Previously a resident in the UK, your date of leaving

Date you first came to live in the UK

Ethnicity

Please indicate your ethnic origin. This is not compulsory, but may help with your healthcare, as some health problems are more common in specific communities, and knowing your origins may help with the early identification of some of these conditions.

New Patient Questionnaire

Are you happy to receive information/appointment reminders via text message? *

Yes No

Communication/Access needs

Do you have any hearing issues? *

Yes No

If YES please provide any additional information

Are you registered blind or partially sighted? *

Yes No

If YES please provide any additional information

What is your first Language *

Do you require an interpreter? *

Yes No

Carers

Do you have anyone who looks after you as a carer? *

Yes No

Do you care for anyone? *

Yes No

Smoking and Alcohol

Are you a Smoker? *

Yes No

If YES how many/ much?

Would you like to stop smoking?

Yes No

Would you like help and advice to stop smoking?

Yes No

If you are an ex-smoker when did you stop smoking?

How many units of alcohol do you consume on an average week? *

Medical History

Medication

We ask that you make sure you have a four week supply of your regular medications from your previous practice as you may need to speak to a GP before you can order your medication from us.

Please list your current regular medications below, including contraception

Do you currently have enough medication to last for one month?

Yes No

If no, please contact your current GP for a months supply as they should provide this for you. If you have any problems please contact our reception team.

Are you allergic to anything (e.g antibiotics, sticking plaster)? *

Yes No

Please list below

Which Pharmacy would you like your prescriptions to go to?

Name of Pharmacy *

Postcode *

Vaccinations

Have you had any vaccinations? If so what were these for and when did you have them?

If you are returning from the armed forces

Address before enlisting

Service/Personnel number

Enlistment date

Complete registration

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.

Signature *

Signature of patient

Signature on behalf of patient

Signed *

Date *

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

Yes No

Name of parent or guardian

Relationship to patient

Signed

Date

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

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 *

Yes No

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

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.

I have an S1 form

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.

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 TICK ONE OF THE FOLLOWING BOXES:

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

signed

date

This form is protected by reCAPTCHA and the Google Privacy Policy and Terms of Service apply.

Registration form with Questionnaire

Further Information

Connect With Us