Adult New Patient Registration

Everyone has a right to register with a GP. You do not need proof of address, immigration status, ID or an NHS number to register at our practice.

This questionnaire is to collect information about your health so that the health professionals at your GP practice can understand what support, treatment and specialist services you may need in accordance with the confidentiality and data sharing policies of the National Health Service.

If you have ID available you can provide this as it may help speed up the registration process but we do not insist on it. Upon registration you will be informed of your named GP and offered to book in with the Healthcare Assistant for a New Patient Health check.

If you are on any medications, where possible you should ensure you have enough supply from your previous practice and provide us with a copy of the repeat slip. You will need to book a routine appointment with the GP within 2 months to review the medication and get them added onto repeat.

Your GP will not disclose any information you provide for purposes other than your direct care unless: you have consented (e.g., to support medical research); or they are required to do so by law (e.g., to protect other people from serious harm); or because there is an overriding public interest (e.g., you are suffering from a communicable disease). Further information about how your GP will use your information is available from reception.

If there is something that you do not feel comfortable sharing in this form and you would like to discuss it with a doctor, please speak to reception or call your GP practice and book an appointment.

To register a new patient you will need to live within our practice boundary.

New Patient Registration - Adult

Patient's Details

Title: *
Please use this date format: DD/MM/YYYY.
Sex: *
i.e. keycode
Any responses we send will go to this email address.
What is your preferred method of contact?

The practice sends text messages to patients regarding appointment information, and any other information necessary. If you do not wish to receive these, please inform us.

Can we contact you by text?
Can we contact you by email?
Which of the following best describes you?
Is this the same gender you were given at birth?

Additional Information

Please specify the ethnic group you consider you belong to:
Religion:
Marital status:
Sexual Orientation:
Main spoken language:
Second spoken language:
Do you need an interpreter?
Do you speak English?
Do you read English?
Would you prefer a male or a female interpreter? Please be aware that interpreter availability might mean it is not always possible to meet your preference.
Are you able to read in your own language?
Are you able to write in your own language?
Do you need sign language support?
Are you an Armed Forces Veteran?
Are you a sex worker?
Are you homeless?
Are you an Asylum Seeker?
Are you a refugee?
Are you a Migrant?
Are you from a Roamer/Traveller community?

Carers

Are you a carer for someone?
Do you have a carer?
Do you give us permission to discuss your medical record with your carer?

Next of Kin

Please give details of your next of kin:
Please include postcode.
Are they your emergency contact?
Do you give us permission to discuss your medical records with them?

Emergency Contact

Please give details of someone we can contact in an emergency:
Please include postcode.
Do you give us permission to discuss your medical records with them?

Alternative Communication

Do you require an alternative method of communication?

Previous Details

Please include postcode.

If you are from abroad

Registering with the NHS for the first time in the UK
Please use this date format: DD/MM/YYYY.

If you are returning from abroad

Previously been registered with the NHS in the UK
Please use this date format: DD/MM/YYYY.
Please use this date format: DD/MM/YYYY.

Supplementary Questions

I am not ordinarily a resident in the UK

Ordinarily Resident

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. Alternatively for more information go to www.nhs.uk/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.

Please select one of the following statements:

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.

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.

EHIC/PRC

Please enter the details from your EHIC or PRC below.

S1 Form

Do you have an 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.