New patient registration (child under 16)

Contact Information

Title: *

Miss

Ms

Master

Other

Please specify other title: *

Surname: *

Previous Surnames:

First Names(s): *

NHS Number:

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

Male

Female

Non-binary

Prefer to self-describe

Is your gender identity the same as the sex you were assigned at birth? *

Yes

No

We are asking for this information to match your GP record.

Current Address: *

Postcode: *

Town and Country of birth: *

Home Phone Number:

Mobile Number: *

Work Phone Number:

Previous Details

Previous address in UK:

Please include postcode.

Name and address of previous GP:

If you are from abroad

Registering with the NHS for the first time in the UK

Are you from abroad?

Yes

No

Your first address where registered with a GP:

Please include postcode.

Date you came to live in the UK: *

If you are returning from abroad

Previously been registered with the NHS in the UK

Date you left the UK:

Please use this date format: DD/MM/YYYY.

Date you returned to the UK:

Please use this date format: DD/MM/YYYY.

Supplementary Questions

I am not ordinarily a resident in the UK

Ordinarily Resident

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.

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. Alternatively for more information go to www.nhs.uk/visitingengland.

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.

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.

A parent/guardian should complete the form on behalf of a child under 16.

Signature:

Print Name:

On behalf of:

Relationship to patient:

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

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 of the GP practice, including at a hospital.

EHIC/PRC

Please enter the details from your EHIC or PRC below.

Country Code:

3. Name:

4. Given Names:

5. Date of Birth:

6. Personal Identification Number:

7. Identification number of the institution:

8. Identification number of the card:

Expiry Date:

PRC validity period – from:

PRC validity period – to:

S1 Form

Do you have an S1 Form?

I 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).

Please give your S1 form to the practice staff.

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.

Armed Forces

Were you ever registered with an Armed Forces GP?

Yes

No

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:

Service or Personnel Number:

Enlistment Date:

Discharge Date (if applicable):

These questions are optional and your answers will not affect your entitlement to register or receive services from the NHS but may improve access to some NHS priority and service charities services.

If you need your doctor to dispense medicines and appliances

Not all doctors are authorised to dispense medicines

I live more than 1.6km in a straight line from the nearest chemist

I would have serious difficulty in getting them from a chemist

Family Members

Please list other family members who are already registered with us (Name and Date of Birth):

Next of Kin Details

Full Name:

Relationship to patient:

Contact Details (Phone Number and Address):

Do you consent to us sharing information with your next of kin about your care?

Yes

No

Required Information

Full Name of Parent(s)/ Carer(s) 1: *

Has legal responsibility? *

Yes

No

Next of kin? *

Yes

No

Full Name of Parent(s)/ Carer(s) 2:

Has legal responsibility?

Yes

No

Next of kin?

Yes

No

Name of person(s) with legal responsibility if not above:

Please give copy of Delegation of Consent Form if you are a carer.

Name of School/ Nursery attended: *

Is the child/ young person home educated? *

Yes

No

Please list other household members at your address: *

Please state if each member of household is registered with us or not

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