New Patient Registration

If you would like to register with the practice please use this form.

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

New Patient Registration - Rebuild

Patient's Details

Title: *
Gender *
Please use date format DD/MM/YYYY
Please tell us your preferred method of contact: *
Do we have permission to send you text messages? *

Previous Details

If you are from abroad

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

If you are returning from abroad

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

Supplementary Questions

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/visitingengland.

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.

European Economic Area (EAA) 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) ?
Please enter the details from your EHIC or PRC below.
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.

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.

NHS Organ Donor Registration

If you wish your medical records to be marked that you are willing to donate organs/tissue for transplantation after your death; please tick:

If you would like to join the NHS Organ Donation Register please visit their website on: www.organdonation.nhs.uk/consent.do

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.

Personal Details:

This is so that the practice can ensure they are identified and accommodated by taking the appropriate action.

Are you a carer?

If you look after a member of your family or a friend who is unwell, frail or disabled, you are a carer.

Carers Details

Are they a patient at this surgery?

Details of person being cared for

Are they a patient at this surgery?

Smoking

I am: *
Please use date format DD/MM/YYYY

Alcohol

A unit is half a pint of beer, a single spirit or a glass of wine.
How often do you have a drink containing alcohol? *
How many units of alcohol do you drink on a typical day when you are drinking? *
How often have you had 6 or more units if female, or 8 or more units if male on a single occasion in the last year? *

Next of Kin

Application for online access to my medical record

I wish to have access to the following online services (please tick)
I wish to access my medical record online and understand and agree with each statement (tick)
In order to opt out of data sharing please ask at reception for further details.
If I don't opt out this means that my medical record will be made available to other medical organisations.

Practice Use Only

Method:
Level of Access Enabled: