PART 1: PATIENT'S DETAILS NHS number (if known) Surname * First names * Town and country of birth * Home address (including postcode) *
(Please also provide flat number or room number where appropriate)
Telephone number * PART 2: PREVIOUS MEDICAL RECORDS
Please help us trace your previous medical records by providing the following information
Your previous address (including postcode) in the UK Name of previous doctor while at that address Address (including postcode) of previous doctor • If you are from abroad Your first UK address (including postcode) where registered with a GP • If you are returning from the Armed Forces Address before enlisting in Armed Forces Service or Personnel number PART 3: CHILDREN UNDER 5 If you are registering a child under 5 PART 4: DISPENSING OF MEDICINES AND APPLIANCES If you need a doctor to dispense medicines and appliances
(Not all doctors are authorised to dispense medicines)
PART 5: ORGAN & BLOOD DONATION • 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.
(Please tick the boxes that apply)
• NHS Blood Donor registration I would like to join the NHS Blood Donor Register as someone who may be contacted and would be prepared to donate blood. My preferred address (including postcode) for donation is:
(only if different from above, e.g. your place of work)
PART 6: 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.
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.
(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.) PATIENT DECLARATION : Please select one of the statements below: *
(Required. Only one selection is permitted)
Print full name * PART 7: NON-UK EUROPEAN HEALTH INSURANCE CARD (EHIC), PROVISIONAL REPLACEMENT CERTIFICATE (PRC) DETAILS
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
• EHIC and/or PRC? Do you have a non-UK EHIC or PRC? PART 8: S1 form Do you have an S1 form? If yes, please give your S1 form to the practice staff.
(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).
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.