Application to Register with a General Medical Practitioner Part 1: Patient's DetailsPreferred TitlePlease Select…MrMrsMissMsMxYour Name First Name Surname Previous Surnames Optional (if applicable)Date of Birth Day Month Year NHS Number Optional (If known)GenderPlease Select…FemaleMaleNon-BinaryTransgenderCISCISHETIntersexRather Not SayCountry and Town of birth Borough of Birth Home Address Street Address Address Line 2 City Postcode (Please also provide flat number or room number where appropriate)Home Telephone Number OptionalMobile Telephone NumberEmail Address Enter Email Confirm Email Further DetailsReligion Optional Marital Status Optional Ethnicity OptionalPlease select…White BritishWhite IrishWhite OtherBlack BritishBlack CaribbeanBlack AfricanBlack OtherAsian IndianAsian PakistaniAsian ChineseAsian OtherWhite & Black BritishWhite & Black CaribbeanWhite & Black AfricanWhite & AsianOtherPlease specify your ethnicity What is your first language? Do you require an interpreter? Are you a student? Yes No Where are you studying? Occupation Optional Contacting You We will from time to time have to contact patients via SMS text message. this is extremely helpful particularly in the current state of pandemic.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? Yes No Previous Medical RecordsPlease help us trace your previous medical records by providing the following information.Have you registered with the NHS before? Yes No Your previous address in the UK Street Address Address Line 2 City Postcode Name of previous doctor while at that address Address of previous doctor Street Address Optional Address Line 2 Optional City Optional Postcode Optional Are you from abroad? Yes No Your first UK address where registered with a GP Street Address Optional Address Line 2 Optional City Optional Postcode Optional If previously resident in UK, date of leaving Day Month Year Date you first came to live in the UK Day Month Year Are you returning from the Armed Forces? Yes No Address before enlisting in Armed Forces Street Address Address Line 2 City Postcode Service or Personnel number Enlistment Date Day Month Year Dispensing Of Medicines And AppliancesIf you need a doctor to dispense medicines and appliances I live more than 1 mile in a straight line from the nearest chemist Optional I would have serious difficulty in getting them from a chemist Optional (Not all doctors are authorised to dispense medicines) Organ & Blood DonationWould you like to register as an organ donor? Yes No 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.I would like to donate: Any of my organs and tissue Optional Kidneys Optional Heart Optional Liver Optional Corneas Optional Lungs Optional Pancreas Optional Any part of my body Optional (Please tick the boxes that apply)Signature (For more information, please ask at reception for an information leaflet or visit the website www.uktransplant.org.uk, or call 0300 123 23 23)Are you/Would you like to register as a blood donor? Yes No 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.Donor Confirmation Tick here if you have given blood in the last 3 years. Signature (For more information, please ask for the leaflet on joining the NHS Blood Donor Register)My preferred address (including postcode) for donation is: Street Address Optional Address Line 2 Optional City Optional Postcode Optional (only if different from above, e.g. your place of work)Patient DeclarationAre you ordinarily resident in the UK? Yes No 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. 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. (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.)PATIENT DECLARATION : Please select one of the statements below: 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 Patient Declaration Conf 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)Signature Optional Are you completing this form on behalf of a child under 16? Yes No Patient's Name First Name Surname (if signing for the person named at the top of this form)Relationship to patient (if signing for the person named at the top of this form)Non-uk European Health Insurance Card (EHIC), Provisional Replacement Certificate (PRC) DetailsComplete 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 UKDo you have a non-UK EHIC or PRC? Yes No Please enter details from your EHIC or PRC below:Country code Name First Name Optional Surname Optional Given Names Optional Date of Birth Day Optional Month Optional Year Optional Personal Identification Number Optional Identification Number of the Institution Optional Identification number of the card Optional Expiry Date Day Optional Month Optional Year Optional PRC Validity PeriodPRC valid From: Day Optional Month Optional Year Optional To: Day Optional Month Optional Year Optional S1 FormDo you have an S1 form? If yes, please give your S1 form to the practice staff. Yes, I have an S1 form, and I will bring or send it to the practice No, I do not have an S1 form (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)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.Proof of Identity and Address ProvidedWe require proof of identity and address – please email a copy of your identity as well as proof of address to [email protected] with “New registration ID” as the subject header. If you do not provide us with proof of ID and address we may be unable to proceed with your registration.Proof of Identity Birth Certificate Driving Licence Passport Proof of Address Other If you have selected "other", please state the type of document provided OptionalComplete RegistrationIf you are registering a child under 5 I wish the child above to be registered with the named doctor for Child Health Surveillance Optional If you need your doctor to dispense medicines and appliances I live more than 1 mile in a straight line from the nearest chemist Optional I would have serious difficulty in getting them from a chemist Optional Signature Signature of patient Signature on behalf of patient Signed (Full Name)
