New patient registration

Patient’s details

Title:

Mr

Mrs

Miss

Ms

Which of the following best describes how you think of yourself?

Male

Female

Non-binary

Prefer to self-describe

Is your gender identity the same as the sex you were assigned at birth? *

Yes

No

We are asking for this information to match your GP record.

First name:

Surname:

Previous surname(s):

NHS Number:

Home Address:

Town and Country of birth:

Postcode:

Telephone:

Email Address:

Previous medical records

Have you previously been registered at another practice?

Yes

No

Name of previous GP practice:

Address of previous GP practice:

Previous address in the UK:

If you are from abroad

Your first UK address where registered with a GP:

Armed Forces

Were you ever registered with an Armed Forces GP?

Yes

No

Which one best applies to you?

Regular

Reservist

Veteran

Family member (spouse, civil partner, service child)

Address before enlisting:

Postcode:

Service or Personnel number:

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 charity services.

Dispensed medicines and appliances

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

Signature of patient

Signature on behalf of patient:

Date

NHS Organ Donor registration

Please tell your family you want to be an organ donor. If you do not want to be an organ donor, please visit www.organdonation.nhs.uk or call 0300 123 23 23 to register your decision.

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.

Have you given blood in the last 3 years?:

Yes

No

Signature confirming my consent to join the NHS blood donor register

Date

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

Postcode

All blood types are needed, especially O negative and B negative. Visit www.blood.co.uk or call 0300 123 23 23.

To be completed by the GP Practice

Supplementary Questions

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

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 select 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

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

Signed:

Date:

Print name:

On behalf of:

Relationship to patient:

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.

Non-UK European health insuance card (EHIC), provisional replacement certificate (PRC) details and S1 forms.

Do you have a non-UK EHIC or PRC?

Yes

No

Please enter details from your EHIC or PRC below:

Country code:

3. Name:

4. Given names:

6. Personal identification number:

7. Identification number of the institution:

8. Identification number of the card:

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 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.

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