New Patient | Online Registration Form

Please complete the form below to register with us. Sections 1 & 6 are required. Other sections are voluntary, but the more information you provide, the better we can help you. If you have any questions, please call the practice during opening hours on: 020 7837 2020

GMS1 Form

* = Required fields

PART 1: PATIENT'S DETAILS

Date of birth *

(dd/mm/yyyy)

NHS number (if known)

Surname *

First names *

Previous surnames

(If applicable)

Town and country of birth *

Home address (including postcode) *

(Please also provide flat number or room number where appropriate)

Telephone number *

Email *

Confirm Email

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 previously resident in UK, date of leaving

(dd/mm/yyyy)

Date you first came to live in the UK

(dd/mm/yyyy)

• If you are returning from the Armed Forces

Address before enlisting in Armed Forces

Service or Personnel number

Armed Forces Enlistment date

(dd/mm/yyyy)

PART 3: CHILDREN UNDER 5

If you are registering a child under 5

I wish the child (named above) to be registered with my named doctor for Child Health Surveillance

PART 4: DISPENSING OF MEDICINES AND APPLIANCES

If you need a doctor to dispense medicines and appliances

I live more than 1 mile in a straight line from the nearest chemist
I would have serious difficulty in getting them from a chemist

(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)

Signature confirming my agreement to organ/tissue donation

(For more information, please ask at reception for an information leaflet or visit the website www.uktransplant.org.uk, or call 0300 123 23 23)

Date of signature

• 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.

Tick here if you have given blood in the last 3 years

Signature

(For more information, please ask for the leaflet on joining the NHS Blood Donor Register)

Date of signature

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: *

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

(Required. Only one selection is permitted)

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)

Date of signature *

Print full name *

On behalf of

(if signing for the person named at the top of this form)

Relationship to patient

(if signing for the person named at the top of this form)

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.

Yes, I have an S1 form, and I will bring or send it to the practice
No, I do not 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).

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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New Patient | Online Registration Form

GMS1 Form

PART 1: PATIENT'S DETAILS

PART 2: PREVIOUS MEDICAL RECORDS

• If you are from abroad

• If you are returning from the Armed Forces

PART 3: CHILDREN UNDER 5

PART 4: DISPENSING OF MEDICINES AND APPLIANCES

PART 5: ORGAN & BLOOD DONATION

• NHS Organ Donor registration

• NHS Blood Donor registration

PART 6: PATIENT DECLARATION

PART 7: NON-UK EUROPEAN HEALTH INSURANCE CARD (EHIC), PROVISIONAL REPLACEMENT CERTIFICATE (PRC) DETAILS

• EHIC and/or PRC?

• Please enter details from your EHIC or PRC below:

• PRC validity period

PART 8: S1 form

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Register

General Policies

Our Practice

Patient Info

Contact

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New Patient | Online Registration Form

GMS1 Form

PART 1: PATIENT'S DETAILS

PART 2: PREVIOUS MEDICAL RECORDS

• If you are from abroad

• If you are returning from the Armed Forces

PART 3: CHILDREN UNDER 5

PART 4: DISPENSING OF MEDICINES AND APPLIANCES

PART 5: ORGAN & BLOOD DONATION

• NHS Organ Donor registration

• NHS Blood Donor registration

PART 6: PATIENT DECLARATION

PART 7: NON-UK EUROPEAN HEALTH INSURANCE CARD (EHIC), PROVISIONAL REPLACEMENT CERTIFICATE (PRC) DETAILS

• EHIC and/or PRC?

• Please enter details from your EHIC or PRC below:

• PRC validity period

PART 8: S1 form

QR Code

Register

General Policies

Our Practice

Patient Info

Contact

Scan here to bring up this website on your mobile device

In order to protect our patients and staff we have opted to continue to wear a face covering whilst in the practice