Previously been registered with the NHS in the UK

Footnote: These questions are optional and your answers will not affect your entitlement to register or receive services from the NHS but may improve access to some NHS priority and service charities services

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 at reception. Alternatively for more information go to the NHS Website

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.

A parent/guardian should complete the form on behalf of a child under 16.

LIST OF EEA COUNTRIES

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.

Please give your S1 form to the practice staff.

Leaving Messages

In accordance with the Data Protection Act, the Practice needs consent form any patient that has an answer phone and is happy for us to leave a message. If we do not have consent, we will be unable to leave a message on an answer phone or with a third party, please tick

Collection of Paperwork

Any patient wishing for someone else to collect their prescriptions/paperwork will have to give the Practice signed consent. Reception staff will not be able to hand a prescription/paperwork over to anyone collecting on someone’s behalf without prior consent.

If you do not return this form, a Summary Care Record will be created for you based on implied consent

Blood Pressure

If you are drinking less than 14 units of alcohol per week, then your drinking is within the UK Chief Medical Officers' low risk drinking guidelines.

But if you are drinking regularly at or above the low risk guidelines of 14 units a week, or, you are drinking six or more units - if you are female - or eight or more units - if you are male - in one single session (binge drinking), please consider the increased serious risks to your health being caused by your current drinking pattern.

You can sign up yourself immediately with NHS APP which will enable you to order repeat prescriptions and view medical records.

NHS Organ Donor registration

More information on Organ Donation

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 or call direct on 03001232323

Patient Participation Groups (PPG's) work with their practices to provide practical support, to help patients to take more responsibility for their own health and to provide strategic input and advice. They are based on cooperation between the practice staff and patients and help to improve communication. Broadly PPG's improve communication within the community through newsletters, websites and other means; organise health promotion events; run services to meet local needs; provide strategic advice and carrying out research and supporting the practice in its dealings with other bodies. The PPG meet on a quarterly basis.

You contact details

Name:  

Email Address: 

Mobile number: 

What happens to my information?

Personal and medical information about patients registered at this practice are primarily kept electronically, although some is kept in paper form. Some information will be sent to hospital consultants and other health professionals to whom you are referred by your GP in order to provide continued healthcare and obtain treatment for you.

We sometimes use accredited suppliers for our communication with you, for example when we send recall letters for review clinics or medication reviews. All suppliers we use are checked carefully to ensure they comply with strict confidentiality protocols.

To ensure the security of all patient information, all staff that has access to your records is covered by confidentiality clauses in their contracts and the Data Protection Act and the Freedom of Information Act. Our guiding principle is that we hold your records in strict confidence.

I certify that the information I have provided is correct and consent to my personal and medical information being used as stated above.