New patient registration (children)

Patient’s Details

Title *

Mr

Miss

Mx

Other

Please specify:

Surname: *

Forename(s) *

Previous Surnames:

Sex *

Male

Female

Indeterminate

NHS Number:

Town and Country of birth: *

Home Address: *

Postcode: *

Home Phone Number:

Mobile Phone Number:

Preferred Phone Number:

Can we contact you by text?

Yes

No

Can we contact you by email?

Yes

No

Name of Parent or Guardian: *

Contact Number of Parent/Guardian: *

Name of Parent or Guardian:

Contact Number of Parent/Guardian:

Name of School Attended:

Ethnic Origin

Please state:

Do you speak English?

Yes

No

Do you read English?

Yes

No

First Language:

Consultations are carried out in English. Please indicate if you will need the services of an interpreter:

Yes I need an interpreter

No I do not need an interpreter

Young Carers and the Cared For

Caring for a family member, friend or neighbour who cannot manage alone is an important and valuable role that can not only be extremely demanding but also very isolating for the carer, especially as the responsibility can exist around the clock seven days per week. We also know that many people who perform these tasks without support may not see themselves as carers but they are carers nevertheless and it is appropriate that they are offered suitable assistance.

Do you look after someone who is ill, frail, disabled or mentally unwell?

If so, you are a carer and the practice would like to support you. If you have not previously registered with the practice as a carer, please ask at reception for a Carers Identification and Registration Form. If you are agreeable, we will then pass your details to those organisations which may be able to provide you with appropriate support.

As a carer, you are entitled to have your needs assessed by Social Services. A Carer’s Assessment will
give you the opportunity to talk about your needs as a carer and explore the possible ways that help could be provided. It also looks at the needs of the person you care for. There is no charge for this type of assessment.

Are you a carer?

Yes

No

Name of person you care for:

Relationship to person you care for:

Address of person you care for:

Are you willing for your name to be passed to the carers’ organisations?

Yes

No

Is the person you care for registered with this practice?

Yes

No

Signature: *

Date:

Does someone care for you?

Yes

No

As someone else cares for you, it is important for us to hold this information in your medical record so please let us have your carer’s name and contact details below:

Title:

Forename(s):

Surname:

Address:

Postcode:

Email:

Home Phone Number:

Work Phone Number:

Mobile Phone Number:

Is your carer registered with this practice?

Yes

No

What is the relationship between you and your carer?

e.g. spouse, partner, son, daughter, employed carer

Do you give us permission to discuss your medical record with your carer?

Yes

No

Previous Details

Previous address in UK (if different from above):

Please include postcode.

Name and address of previous GP:

If you are from abroad

Registering with the NHS for the first time in the UK

Your first UK address where registered with a GP:

Please include postcode.

Date you came to live 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

Date you left the UK:

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

Date you returned to the UK:

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

Were you ever registered with an Armed Forces GP

Please indicate if you have served in the UK Armed Forces and/or been registered with a Ministry of Defence GP in the UK or overseas:

Regular

Reservist

Veteran

Family Member (Spouse, Civil Partner, Service Child)

Address before enlisting (including postcode):

Service or Personnel Number:

Enlistment Date:

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

Discharge Date (if applicable):

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 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

No

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

Yes

No

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.

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Patient’s Details

Ethnic Origin

Young Carers and the Cared For

Do you look after someone who is ill, frail, disabled or mentally unwell?

Previous Details

If you are from abroad

If you are returning from abroad

Were you ever registered with an Armed Forces GP

Supplementary Questions

Ordinarily Resident

European Economic Area (EEA) Country

EHIC/PRC

S1 Form

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