New Patient Registration Form

NHSFamily doctor services registrationGMS1

Patient's Details

Radio Buttons *

Mrs

Miss

Surname: *

Date of Birth: *

Please use this date format: DD/MM/YYYY.

First Name(s) *

NHS Number:

Previous Surnames:

Radio Buttons *

Male

Female

Indeterminate

Town and Country of birth: *

Home Address: *

Postcode: *

Phone Number: *

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

Your previous address in UK:

Name of previous doctor while at that address:

Address of previous doctor:

If you are from abroad

Your first UK address where registered with a GP:

If previous resident in UK, date of leaving:

Please use this date format: DD/MM/YYYY.

Date you first came to live in UK:

Please use this date format: DD/MM/YYYY.

If you are returning from the armed forces

Address before enlisting:

Service or personnel number:

Enlistment date:

Please use this date format: DD/MM/YYYY.

If you are registering a child under 5

Child Surveillance:

I wish the child above to be registered with the doctor named overleaf for Child Health Surveillance

If you need your doctor to dispense medicines and appliances*

*Not all doctors are authorised to dispence medicines

Dispensing:

I live more than 1 mile in a straight line from the nearest chemist

I would have serious difficulty in getting them from a chemist

NHS Organ Donor registration

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.

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. Please select all that apply:

Checkboxes

Signature confirming my agreement to organ/tissue donation

NHS Blood Donor registration

For more information, please ask for the leaflet on joining the NHS Blood Donor Register

I would like to join the NHS Blood Donor Register as someone who may be contacted and would be prepared to donate blood.

I have given blood in the last 3 years

Checkboxes

Signature confirming consent to inclusion on the NHS Blood Donor Register

Checkboxes *

Signature

Signature of behalf of Patient

Date: *

Supplementary Questions

I am not ordinarily a resident in the UK?

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/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 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.

Signature

Print Name

On behalf of

Relationship to patient

Date

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?

Yes

Do you have a non-UK European Health Insurance Card (EHIC) or a Provisional Replacement Certificate (PRC) ?

Yes

For more information about the European Health Insurance Care (EHIC), visit: www.nhs.uk/ehic.

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.

Country Code

3. Name

4. Given Names

5. Date of Birth

6. Personal Identification Number

7. Identification number of the institution

8. Identification number of the card

9. Expiry Date

PRC validity period - from:

PRC validity period - to:

S1 Form

Do you have an S1 Form?

I 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).

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.

Brentford Family Practice

Brentford and Isleworth Primary Care Network

Patient's Details

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

If you are from abroad

If you are returning from the armed forces

If you are registering a child under 5

If you need your doctor to dispense medicines and appliances*

NHS Organ Donor registration

NHS Blood Donor registration

Supplementary Questions

Ordinarily Resident

European Economic Area (EEA) Country

EHIC/PRC

S1 Form

How will your EHIC/PRC/S1 data be used?

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