Adult Registration Form

Personal Details

Title *

Mr

Mrs

Miss

Ms

Surname *

First Names: *

Marital Status *

NHS Number: *

Previous Surname(s):

Sex: *

Male

Female

Indeterminate

Town and Country of Birth: *

Please provide your address and postcode: *

Telephone Number: *

Parents and Guardians

If you have any parents or guardians, please state their names and relationship to you.

Full name:

Relationship:

Full name:

Relationship:

Height and Weight

Height: *

Weight: *

Ethnic Origin

Please specify your ethnic origin: *

Language

Please specify your main or first language spoken/understood: *

Next of Kin

Please provide the details of your next of kin.

Title: *

Mr

Mrs

Miss

Ms

Next of kin name: *

Relationship to patient *

Telephone number: *

Mobile number: *

Date of birth *

Please use this date format: DD/MM/YYYY

Next of kin address and postcode: *

Alcohol Consumption

How often do you have a drink that contains alcohol? *

How many units do you have in a typical day when you are drinking? *

In the last 6 months, how often have you had more than 6 units on any one occasion if female, or more than 8 units if male? *

Smoking

Do you smoke? *

Yes

No

If you do currently smoke, how many cigarettes or ounces of tobacco do you smoke per week? *

Would you like advice on giving up smoking? *

Yes

No

Have you ever smoked? *

Yes

No

Exercise

How often do you exercise? *

Type(s) of exercise:

Your Medical Background

Do you have medical problems at present? *

Do you have any sensitivities or allergies? *

Please list any tablets, medicines or other treatments you are currently taking (including dosage and frequency): *

Please note you will need to book an appointment with the GP before requesting repeatable medication.

Are you able to administer your own medicines? *

Yes

No

Please detail specific issues (e.g swallowing, openings containers): *

Please specify *

Specific Needs

Please detail below any specific needs you have so the practice can ensure they are identified and accommodated by take the appropriate action.

Are you an assistance dog user: *

Yes

No

Please state any sensory impairment you have (i.e speech, hearing, sight): *

Please state any physical disabilities you have: *

Please state any mental disabilities you have: *

Please state any requirements you have to be able to access the practice premises: *

Do you require the help of a translator/interpreter? *

Yes

No

Please state any specific nutritional requirements you have: *

Please state any phobias you have: *

If you are a carer, please state the name/address/phone number of the person you care for: *

If you have a carer, please state their name/address/phone number: *

Sign here if you wish us to disclose information about your health to your carer.

Signature:

Date:

Have you nominated to speak to someone on your behalf (e.g a person who has Power of Attorney)? *

Yes

No

Please provide their name/address/phone number: *

Patient Participation Group

The practice is committed to improving the services we provide to our patients. To do this, it is vital that we hear from people about their experiences, views, and ideas for making services better.

By expressing your interest, you will be helping us to plan ways of involving patients that suit you. It will also mean we can keep you informed of opportunities to give your views on developments within the practice.

The group consists of patients that attend regular meetings and also virtual members that participate via email.

If you are interested in joining our Patient Participation Group, please confirm by ticking yes: *

Yes

No

Patient Signature:

Signature on behalf of patient:

Women Only

Please provide the date of your last smear test:

Please use this date format: DD/MM/YYYY

Was this at your GP surgery?

Yes

No

What was the result of the smear?

Date of last mammogram (if applicable):

Please use this date format: DD/MM/YYYY

Method of contraception (if used):

Do you wish to see a doctor in this practice for contraceptive services (including the pill)? *

Yes

No

Text Messages

To receive SMS text messages for appointments and your healthcare please tick the appropriate box: *

Opt-In

Opt-Out

Summary Care Record

The Summary Care Record (SCR) is a summary of a patient's sensitivities, allergies and current medication, which is uploaded to the national Spine so that it can be accessed by any legitimate NHS clinician, regardless of the computer system they use.

The circumstances when this is beneficial include when a patient is seen at a hospital or out of hours unit or when a temporary resident is seen at a GP practice.

It is advisable to stay registered for this service.

To stay registered for the Summary Care Record, please tick the appropriate box: *

Opt-In

Opt-Out

If you would like your child/children to be registered for the Summary Care Record, please provide their name(s):

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

Previous Address in UK:

Please include postcode.

Name and address of previous GP practice:

If you are from abroad

Registering with the NHS for the first time in the UK.

First UK address where registered with a GP:

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 UK:

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

Date you returned to UK:

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

Were you ever registered with the armed forces:

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:

Postcode:

Service personnel number:

Enlistment date:

Discharge date:

If you need your doctor to dispense medicines and appliances

Not all doctors are authorised to dispense medicines

I live more than 1.6km in a straight line from the nearest chemist

I would have serious difficulty in getting them from a chemist

Organ Donation:

For more information on organ donation please visit: www.organdonation.nhs.uk

NHS Blood Donor Registration

If you would like to join the NHS Blood Donor Register as someone who may be contacted and would be prepared to donate blood, please visit their website on: www.blood.co.uk or call direct on 03001232323

Supplementary Questions

I am not ordinarily a 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. 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

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.

Please enter the details from your EHIC or PRC below.

County 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.

I declare to the best of my belief this information is correct:

Signature: *

Date:

Signature of Patient

Signature on Behalf of Patient

Please upload any relevant evidence in support of your registration.

Maximum upload size: 67.11MB

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Personal Details

Parents and Guardians

Height and Weight

Ethnic Origin

Language

Next of Kin

Alcohol Consumption

Smoking

Exercise

Your Medical Background

Specific Needs

Patient Participation Group

Women Only

Text Messages

Summary Care Record

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

If you are from abroad

If you are returning from abroad

Were you ever registered with the armed forces:

If you need your doctor to dispense medicines and appliances

Organ Donation:

NHS Blood Donor Registration

Supplementary Questions

European Economic Area (EEA) Country

S1 Form

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

Flu