Details of registering patient Title (Mr, Mrs, etc) Mr Mrs Miss Ms Home Address
Please help us trace your previous medical records by providing the following Have you previously been registered at a GP? If you are from abroad
Please enter details here if this is your 1st UK NHS registration
Are you from abroad? If you are returning from the Armed Forces Were you ever registered with an Armed Forces GP Please indicate if you have ever served in the UK Armed Forces and/or been registered with a Ministry of Defence GP in the UK or overseas Regular Reservist Family Member Veteran We are unable to register you with the details you have provided. Please go back and review your answers. If you are unable to continue, contact the practice. If you submit the form at this stage your details will not be sent to the practice and you will need to complete the form again. Alternatively select the 'back' option to review your answers. If you need your doctor to dispense medicines and appliances* *Not all doctors are authorised to dispense medicines Signature of patient or Signature on behalf of patient 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. For more information, please ask for the leaflet on joining the NHS Organ Donor Register
Do you want to register your details on the NHS Organ Donor Register as someone whose organs/tissue may be used for transplantation after death. Please tick the boxes that apply By ticking the patient’s name in this box, I confirm - that I am the patient or the patient’s authorised representative - that the information provided is correct to the best of my knowledge NHS Blood donor registration Would you like to join the NHS Blood Donor Register as someone who may be contacted and would be prepared to donate blood. Do you have a preferred address for donation? (only if different from above, e.g. your place of work) Patient declaration 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. 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. 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.
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.
Are you ordinarily resident in the UK Please tick one of the following boxes Are you a parent or guardian, filling out this form on behalf of a child under 16? A Parent/Guardian should complete the form on behalf of a child under 16. By ticking the patient’s name in this box, I confirm that I am the patient or the patient’s authorised representative and that the information provided is correct to the best of my knowledge Non-UK European Health Insurance Card (EHIC), Provisional Replacement Certificate (PRC) details and S1 forms
Complete 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 UK. 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 the GP practice, including at hospital).
Do you have a non-UK EHIC or PRC? Please tick if you have an S1 (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.
Summary care record Summary care record
If you are registered with a GP practice in England you will already have a Summary Care Record (SCR), unless you have previously chosen not to have one. It will contain key information about the medicines you are taking, allergies you suffer from and any adverse reactions to medicines you have had in the past.
Information about your healthcare may not be routinely shared across different healthcare organisations and systems. You may need to be treated by health and care professionals that do not know your medical history. Essential details about your healthcare can be difficult to remember, particularly when you are unwell or have complex care needs.
Having a Summary Care Record can help by providing healthcare staff treating you with vital information from your health record. This will help the staff involved in your care make better and safer decisions about how best to treat you.
You have the choice of what information you would like to share and with whom. Authorised healthcare staff can only view your SCR with your permission. The information shared will solely be used for the benefit of your care.
Your options are outlined below; please indicate your choice on the form below.
Express consent for medication, allergies and adverse reactions only. You wish to share information about medication, allergies and adverse reactions only.
Express consent for medication, allergies, adverse reactions and additional information. You wish to share information about medication, allergies and adverse reactions and further medical information that includes: Your significant illnesses and health problems, operations and vaccinations you have had in the past, how you would like to be treated (such as where you would prefer to receive care), what support you might need and who should be contacted for more information about you.
Express dissent for Summary Care Record (opt out). Select this option, if you DO NOT want any information shared with other healthcare professionals involved in your care.
If you require any more information, please visit http://digital.nhs.uk/scr/patients or phone NHS Digital on 0300 303 5678 or speak to your GP practice.
You are free to change your decision at any time by informing your GP practice.
Your options are outlined below; please indicate your choice on the form below. By ticking the patient's name in this box, I can confirm that I am the patient or the patient's authorised representative and that the information provided is correct to the best of my knowledge Personal information Do you speak English? Please state your ethnicity Asian Other White British White Irish White Other Black British Black Caribbean Black African Black Other Asian Indian Asian Pakistani Asian Chinese White & Black British White & Black Caribean White & Asian Other Health Questionnaire
Please list any serious illnesses / operations / accidents / disabilities (and for women any pregnancy related problems) and the year they took place
Please use the following format for multiple events:
Are you allergic to any medicines? Has anyone in your family had any of the following serious illnesses? Please list any conditions that affect your mental health and state the year(s) when you were first diagnosed
Please use the following format for multiple options:
Women's Health What was your sex at birth? Have you ever had a cervical smear / HPV test? Have you ever had a hysterectomy (removal of womb)? Have you ever had a bilateral oophorectomy (removal of ovaries)? Lifestyle What is your current smoking status? Would you like advice on giving up smoking? Do you take regular exercise? Alcohol Do you drink alcohol? How often do you have a drink containing alcohol? How many standard drinks containing alcohol do you drink on a typical day when you are drinking? How often have you had 6 or more standard drinks on a single occasion in the last year? Patient Participation Group
We would like to invite you to join our Patient Participation Group! Do you want to improve health and health services in your local community? Do you want to have the opportunity to have a voice and get involved in the way your health service is run? Do you want to help shape and improve services and even get involved in shaping and delivering new and exciting services?
Would you like to become a member of Patient Participation Group? Are you happy to be contacted by email? Signature
Please note - if there are any queries we will contact you in order to obtain more information. your registration may not be processed until this information is obtained. Also, you may not be able to see a GP until you have had a new patient health check with our nursing team.
By ticking the patient's name in this box, I confirm that I am the patient or the patient's authorised representative, and that the information provided is correct to the best of my knowledge