Online Registration Form - Amwell Group Practice

Amwell GMS1

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

Part 1: Patient's Details

Preferred Title

Your Name

First Name Surname

Previous Surnames Optional

(if applicable)

Date of Birth

NHS Number Optional

(If known)

Which option best describes how you think of yourself?

Is your gender identity the same as the gender you were given at birth?

Yes Optional

No Optional

Are you intersex?

Yes Optional

No Optional

Which option best describes how you think of yourself?

Town and country of birth

Home Address

Street Address Address Line 2 City Postcode

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

Contact Number

Email Address

Enter Email Confirm Email

Part 2: Previous Medical Records

Please help us trace your previous medical records by providing the following information.

Have you registered with the NHS before?

Yes

Your previous address in the UK

Street Address Address Line 2 City Postcode

Name of previous doctor while at that address

Address of previous doctor

Street Address Optional Address Line 2 Optional City Optional Postcode Optional

Are you from abroad?

Yes

Your first UK address where registered with a GP

Street Address Optional Address Line 2 Optional City Optional Postcode Optional

If previously resident in UK, date of leaving

Date you first came to live in the UK

Are you returning from the Armed Forces?

Yes

Address before enlisting in Armed Forces

Street Address Address Line 2 City Postcode

Service or Personnel number

Enlistment Date

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 Optional

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 Optional

I would have serious difficulty in getting them from a chemist Optional

(Not all doctors are authorised to dispense medicines)

Part 5: Organ & Blood Donation

Would you like to register as an organ donor?

Yes

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.

I would like to donate:

Any of my organs and tissue Optional

Kidneys Optional

Heart Optional

Liver Optional

Corneas Optional

Lungs Optional

Pancreas Optional

Any part of my body Optional

(Please tick the boxes that apply)

Signature

(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)

Are you/Would you like to register as a blood donor?

Yes

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.

Donor Confirmation

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)

My preferred address (including postcode) for donation is:

Street Address Optional Address Line 2 Optional City Optional Postcode Optional

(only if different from above, e.g. your place of work)

Part 6: Patient Declaration

Are you ordinarily resident in the UK?

Yes

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

Patient Declaration Conf

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 Optional

Are you completing this form on behalf of a child under 16?

Yes

Patient's Name

First Name Surname

(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

Do you have a non-UK EHIC or PRC?

Yes

Please enter details from your EHIC or PRC below:

Country code

Name

First Name Optional Surname Optional

Given Names Optional

Date of Birth

Personal Identification Number Optional

Identification Number of the Institution Optional

Identification number of the card Optional

Expiry Date

PRC Validity Period

PRC valid From:

To:

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.