Adult new patient registration (16 and over)

Patient’s Details

Title *

Please specify: *

Surname: *

Previous Surnames:

First Name(s) *

Date of Birth: *

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

NHS Number:

Sex *

Male

Female

Do you identify with the gender you were assigned at birth?

Yes

No

Sexual orientation:

Other sexuality:

Town and Country of birth: *

Home Address: *

Postcode: *

How many adults live at this address?

How many children live at this address?

Email Address: *

Any responses we send will go to this email address.

Home Phone Number:

Mobile Phone Number:

Work Phone Number:

Do we have your consent to contact you by text?

Yes

No

Do we have your consent to contact you by email?

Yes

No

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Ethnicity

Please specify the ethnic group you consider you belong to: *

Please state: *

Do you speak English?

Yes

No

Do you read English?

Yes

No

First Spoken Language: *

Do you need an interpreter?

Yes

No

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Emergency Contact

Full Name:

Relationship to you:

Phone Number:

Are they your next of kin?

Yes

No

Do you give us permission to discuss your medical records with them?

Yes

No

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Previous Details

Do you have a previous address in the UK? *

Yes

No

Previous address in UK: *

Please include postcode.

Have you previously been registered with a GP in the UK? *

Yes

No

Name and address of previous GP: *

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If you are from abroad

Registering with the NHS for the first time in the UK

Date you came to live in the UK:

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

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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.

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Supplementary Questions

I am not ordinarily a resident in the UK

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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:

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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.

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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:

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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.

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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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Additional Information

Do you have a carer? *

Yes

No

Are you a carer for someone? *

Yes

No

Name of carer:

Phone Number:

Address:

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

Yes

No

Are you an asylum seeker or refugee?

Yes

No

Are you a British military veteran?

Yes

No

Which branch?

Army

Air Force

Navy

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Height: *

Weight: *

Smoking Status: *

Current Smoker

Ex Smoker

Never Smoked

E-cig Smoker

How many do you smoke per day?

Are you interested in advice on how to quit? *

Yes

No

The practice can provide you with details to the local stop smoking team.

How many did you smoke per day?

When did you stop?

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Please state how much exercise and what type of exercise you do per week:

Do you drink alcohol?

Yes

No

Alcohol Consumption

This is one unit of alcohol:

Amount of different types of drink representing one unit of alcohol

And each one of these, is more than one unit:

Amount of different types of drink representing more than one unit of alcohol

How often do you have a drink containing alcohol? *

How many units of alcohol do you drink on a typical day when you are drinking? *

How often have you had 6 or more units if female, or 8 or more if male, on a single occasion in the last year? *

Score:

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When was your last cervical smear?

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

Was it done at:

A Previous GP

A Family Planning Clinic

What was the result of the cervical smear?

Have you had a hysterectomy?

Yes

No

What type of hysterectomy?

Do you still have your ovaries?

Yes

No

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Immunisation History

Please list any immunisations/vaccinations you have had:

Please include dates.

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Medical History

Do you wear glasses?

Yes

No

Are you registered partially sighted or blind?

No

Partially sighted

Registered blind

Do you wear hearing aids?

Yes

No

Do you have any problems with your mobility?

Yes

No

Please describe your mobility issues:

Do you have any long term health conditions?

Please include dates.

Past operations:

Please include dates.

Are you currently taking any prescribed medication?

Provide name and dosage

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Allergies

Do you have any allergies?

Yes

No

Please specify what you are allergic to, what happens and when you had your first reaction:

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Family History

Do you have any close family members with the following conditions (Mother, Father, Siblings, Grandparents, Aunts or Uncle)? Breast cancer, bowel cancer, diabetes, heart attack, hypertension or stroke:

Please include dates.

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Named Accountable GP

The named accountable GP for The Quays Practice is Dr Ramzan Salim.

Please note this does not prevent you from seeing the clinician of your choice.

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Nominate a Pharmacy

Name and postcode of the pharmacy you wish your prescriptions to be sent electronically to:

If left blank, the nearest pharmacy to your home address will be selected.

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

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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

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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.

Signature: *

Date:

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Photographic ID

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Please upload a photo or scanned copy of your photographic ID (passport or driving licence). If you do not have a passport or driving licence, please supply something with your name and DOB on.

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Adult new patient registration (16 and over)

Patient’s Details

Ethnicity

Emergency Contact

Previous Details

If you are from abroad

If you are returning from abroad

Supplementary Questions

Ordinarily Resident

European Economic Area (EEA) Country

EHIC/PRC

S1 Form

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

Additional Information

Lifestyle

Alcohol Consumption

This is one unit of alcohol:

And each one of these, is more than one unit:

Adult Females only

Immunisation History

Medical History

Allergies

Family History

Named Accountable GP

Nominate a Pharmacy

NHS Organ Donor registration

NHS Blood Donor registration

What happens to my information?

Photographic ID