Over 16's Registration Form

Registrations can take up to 4 weeks to complete.

You will not receive a confirmation of registration.

Please contact the practice to book a 'New Patient Healthcheck' with one of our Nurses.

Last Updated: 20/02/2024

Patient Details

NHS Number:

Title:

Mrs

Miss

Other

First Name: *

Surname: *

Previous Surname: *

Date of Birth: *

Home Address: *

Postcode: *

Town and Country of Birth: *

Your previous address in the UK:

Name of previous GP Practice whilst at that address:

Home Telephone Number:

Mobile Telephone Number:

Work Telephone Number:

I consent to be contacted by SMS on this mobile phone number:

Yes No

Email Address:

I consent to be contacted by email at this email address:

Yes No

Next of Kin Name:

Next of kin relationship:

Next of kin address and telephone number:

If you are from abroad

First UK address where registered with a GP:

Date you first came to live in the UK: *

If previously a UK resident in the UK, date of leaving:

I am not ordinarily a resident in the UK. 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.

Were you ever registered with an Armed Forces GP

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:

Postcode:

Service or Personnel Number:

Enlisting Date:

Discharge 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

Country Code:

Personal Identification Number:

Identification number of the institution:

Identification number of the card:

Expiry Date:

PRC validity period - from and to:

Other Details

Ethnicity:

Religion:

Housing:

Employment:

Which of the following best describes how you think about yourself?

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

Yes No

Which of the following best describes you?

Communication Needs

What is your main spoken language?

Do you need an interpreter?

Yes No

Do you have any communication needs?

Yes No

Communication:

Do you have a learning disability?

Yes No

Carer Details

Only add the carers details if they have given their consent to have those details stored on your medical record.

If you are a carer please visit our website for information on carer support services.

Are you a carer?

Yes - Informal/Unpaid Carer

Yes - Occupational/Paid Carer

Are you a foster carer?

Yes No

Do you have a carer?

Yes No

Name, address, telephone number and relationship of the carer/person being cared for

Medical History

Have you been recently diagnosed with any of the following conditions?

Any other conditions, operations or hospital admission details

If you are currently under the care of a hospital or consultant outside our area, please tell us here:

Family History

Please record any significant family history of close relatives with medical problems and confirm which relatives e.g. mother, father, brother, sister, grandparent

Please specify which relatives:

Allergies

Please record any allergies or sensitivities below:

Your Lifestyle

If you would like further information regarding help to quit smoking please see www.nhs.uk/smokefree

Further Details

If you would like your prescriptions to be sent electronically, please provide details of the pharmacy you would like to use:

Would you like to be involved in our patient participation group? - The PPG helps us gain valuable feedback from our patients during face to face meetings or as a virtual member

Yes No

Sharing your Health Record

Do you consent to your GP Practice sharing your health record with other organisations who care for you?

Yes No

Do you consent to your GP Practice viewing your health record from other organisations who care for you?

Yes No

Do you consent to having an enhanced summary care record with additional information?

Yes No

Online Access to your Health Record

All over 16 year olds have access to their own online health record.

13 - 15 year old patients will not be able to register for online access.

Please present in person at the practice with photographic proof of identification in order to register for online services.

I wish to have online access to:

Request medication

View my summary care record

View my detail coded medical record (subject to policy)

I wish to access my medical record and understand and agree with each statement:

I have read and understood the ‘Important Information about Your Health Care Record’ page

I will be responsible for the security of the information that I see or download

If I choose to share my information with anyone else, this is at my own risk

I will contact the practice as soon as possible if I suspect that my account has been accessed by someone without my agreement

If I see information in my record that it not about me, or is inaccurate I will log out immediately and contact the practice as soon as possible

Signatures

I confirm that the information I have provided is true to the best of my knowledge

Signature:

Signed on behalf of the patient:

Yes No

Name:

Date:

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Over 16's Registration Form

Further Information