Adult New Patient Registration

Patient's Details

Please specify:

Surname: *

Previous Surnames:

First Name(s) *

Calling/Preferred Name:

Date of Birth: *

Please use this date format: DD/MM/YYYY

Sex: *

Male

Female

Indeterminate

NHS Number:

How to find your NHS Number

Town and Country of birth: *

Home Address: *

Postcode: *

Home Phone Number:

Mobile Phone Number: *

Work Phone Number:

Do you agree that you can be contacted, via email and/or SMS, for appointment reminders, reminders for health prevention, screenings and reviews?

Yes

No

Are you a student?

Yes

No

I am a student at:

Information about You

What is your ethnic group?

Please select one option that best describes your White ethnic group or background from the options below: *

Please select one option that best describes your Mixed ethnic group or background from the options below: *

White and Black Caribbean

White and Black African

White and Asian

Any other Mixed background

Please select one option that best describes your Asian or Asian British ethnic group or background from the options below: *

Indian

Pakistani

Bangladeshi

Any other Asian or Asian British background

Please select one option that best describes your Black or Black British ethnic group or background from the options below: *

Please select one option that best describes your other ethnic group or background from the options below: *

Chinese

Filipino

Any other ethnic group or background

Please specify your ethnic group or background: *

What is your first language?

Do you need an interpreter?

Yes

No

Do you have a religious affiliation you would like us to be aware of?

Next of Kin

Full Name:

Relationship to you:

Phone Number:

Previous Details

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

Date you came to live in the UK:

Please use this date format: DD/MM/YYYY

Your first UK address where registered with a GP:

Please include postcode.

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

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.

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

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/nhs-services/visiting-or-moving-to-england.

I am not ordinarily a resident in the UK

Ordinarily Resident

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

Information about You

Next of Kin

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?

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