Fields marked "REQUIRED" are compulsory.. You should only send this form if you are sure that you are eligible to join this practice. Sending this form will NOT automatically register you with the surgery. Sending this form does NOT guarantee or even imply that you will be accepted onto the practice register.

Last Updated: 14/01/2021

SUPPLEMENTARY QUSTIONS / 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 properly settled basis for the time being. In mos 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 ar not ordinarily resident here are exempt from all treatment charges. More information on rdinary resident, exemptions and paying for NHS services can be found in the Visitor and Mirgrant patient leaflet, available from your GP practice, otherwise you may be charged for your reatment. 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 asist in identifying your chargeable status, and may be shared, including with NHS secondary care organisations (e.g. hospitals) and NHS Digital, for th purposes of validation, invoicing and cost recovery. you may be contacted on behalf of the NHS to cofirm any details you have provided.

Personal Details

Home Address Details

Current Contact Details

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

If you are from abroad

If you are returning from the armed forces

Next of Kin / Family Details

About You

Caring Responsibilities

Caring for a child

Caring Responsablity

Caring for an adult

Do you have a carer

Any other adults who reside in your home

Medical History - Women

Personal Medical History

Current Medications

Immunisation History

Please give the date of your immunisations

Childhood Illness

For patients aged 65 and over, or those patients with chronic disease (e.g. asthma or diabetes)

Lifestyle History

Online Services Registration

Summary Care Record Sharing

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. For more information, please ask for the leaflet on joining the NHS Organ Donor Register

NHS Blood Donor Registration

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

Patients Declaration

By signing below you are declaring that the information contained within this patient registration form is accurate to the best of your knowledge. Any suspected fraudulent information will be reported to the relevant authorities.

Non-UK European Health Insurance Card (EHIC), Provisional Replacement Certificate (PRC), details and S1 Forms

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. 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 the GP practice, including at hospital).

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 of Work and Pensions for the purpose of recovering your NHS costs from your home country.