New Patient Registration Form (GMS1) and Patient questionnaire V2

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. Your details will be held at the surgery for a limited period of time. You are required to present in person to sign your registration form and provide proof of your address. Sending this form does NOT guarantee or even imply that you will be accepted onto the practice register.

Last Updated: 16/02/2022

Patients Details

Please complete GMS1 form below. Please enter N/A if it doesn't apply to you. Thank you














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





Complete Registration





NHS Blood Donor Registration

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





SUPPLEMENTARY QUESTIONS | 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. 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. 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.






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

Patient Questionnaire

Please complete the questions below











Next of kin details










Information About You




Carers






Accessible Information






Armed Forces



Alcohol





Smoking





Allergies



Existing Medical Conditions





Your Summary Care Record (SCR) and Your Electronic Patient Record and the Sharing of Information





Sharing Consent - Under 18 years

Children under 18 will automatically have their records shared in and out to enable the Practice to Safeguard their wellbeing by ensuring that data is shared across Child Health and Social Care

Electronic Prescribing


Proof of Identity and Address Provided








Online Access- Age 16 and Over

As of 1st April 2019 the Department of Health have said all 'newly' registered patients should have full record online access, from the date of registration. However, exemptions may apply Please read the information contained in the link below. https://www.england.nhs.uk/wp-content/uploads/2016/11/pat-guid-need-to-know.pdf Provided we have received valid proof of identity we will register you for online services. You will be notified of your username and password