New patient registration with Child Immunisations

New Patient Registration Form With Child Immunisations

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.

Patients Details

Title

Surname *

First name(s) *

Previous Surname

Birth Town *

Birth Country *

Date of Birth *

NHS number

Sex

Male

Female

Marital Status

Address *

Postcode *

Telephone *

I am a student at:

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

Your previous address in UK

Name of previous GP while at previous address

Address of that Doctor

If you are from abroad

Date you first came to live in UK *

Your first UK address where registered with a GP

If previously resident in UK, date of leaving

If you are returning from the armed forces

Address before enlisting

Service/Personnel No.

Enlistment date

CONTACTING YOU

Do you agree that you may be contacted from time to time, via email and/or SMS, with practice news, advice about my health and/or appointment reminders? *

Yes No

Mobile telephone number:

Email address:

SIGNATURE *

DATE *

Online Access

Online access lets you book appointments, order repeat prescriptions and consult with your doctor online.

Would you like access to online services?

Yes No

PROOF OF IDENTITY AND ADDRESS PROVIDED

You will need to provide proof of identity to register for online access. Please contact the surgery to show proof of ID. You are able to have proxy access for children age 0-12, please give names to request access. Please select what identity document you will provide.

Identity Document Type: *

Name of child for proxy access?

Electronic Prescription Collection

All patients need to have a nominated pharmacy for electronic prescription collection (EPS).

Please give name and address of pharmacy:

Information about you

Which of the following best describes your sexual orientation?

Heterosexual

Lesbian

Gay

Bisexual

Prefer not to say

What is your height? *

What is your weight? *

What is your ethnic group? *

What is your Religion?

What is your first language? *

Do you need an interpreter? *

Yes

What is your Occupation?

Do you exercise? (Walk, swim, cycle, other)

If yes, how often per week do you exercise?

MEDICAL INFORMATION

Please list any serious illnesses / operations / accidents / disabilities (and for women any pregnancy related problems) and the year they took place.

FOR PATIENTS AGED 65 AND OVER OR THOSE WITH A CHRONIC DISEASE (E.G. ASTHMA OR DIABETES)

Have you had a flu vaccination? Enter date or 'never': * *

Have you had a pneumococcal vaccination? Enter date or 'never'. *

ALCOHOL

MEN: How often do you have EIGHT or more drinks on one occasion?

WOMEN: How often do you have SIX or more drinks on one occasion?

How often during the last year have you failed to do what was normally expected of you because of drinking? *

In the last year has a relative, friend, a doctor or other health worker been concerned about your drinking or suggested you cut down? *

WOMEN

Have you ever had a cervical smear? *

Yes No

If 'yes', please state when, where and the result.

Are you pregnant?

Yes

If yes, how many weeks?

FAMILY HISTORY

Please state any serious illness, in particular cancer, heart disease, stroke, high blood pressure, diabetes or any inherited disease in your family. Please state your relationship to the individual and in the case of cancer, the type of cancer. *

Is there a history of any of the following in your family?

Breast Cancer

Cancer

Stroke

High blood pressure

Asthma

Diabetes

Heart disease

If yes please give details. (what relative an age)

SMOKING

Do you smoke? *

Yes

Never

Have you ever smoked? If so how many per day?

When did you stop?

If yes, you do currently smoke, how many cigarettes do you smoke per day?

Would you like advice on giving up smoking? *

Yes No

CARERS

Do you have a carer? *

Yes No

Do you look after someone with long term health conditions / Disability? *

Yes No

If yes, please give details

Are you a carer? *

Yes No

If yes please give details.

NEXT OF KIN

Please give name, address, telephone number, email address and relationship of next of kin. *

Child Immunisation History

This section of the form is only to be completed if you are registering a child at the practice.

Complete Registration

If you are registering a child under 5

I wish the child above to be registered with the named doctor for Child Health Surveillance

If you need your doctor to dispense medicines and appliances

I live more than 1 mile in a straight line from the nearest chemist

I would have serious difficulty in getting them from a chemist

Signature

Signature of patient

Signature on behalf of patient

Signed

Date

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

Please tick the boxes that apply:

Any of my organs and tissue or

Kidneys

Heart

Liver

Corneas

Lungs

Pancreas

Any part of my body

Signature confirming consent to organ donation

Date

NHS Blood Donor Registration

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

I would like to join the NHS Blood Donor Register as someone who may be contacted and would be prepared to donate blood.

Tick here if you have given blood in the last 3 years

Signature confirming consent to inclusion on the NHS Blood Donor Register

Date

Preferred address for donation: (if different from above, e.g. place of work)

Postcode

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.

Please tick one of the following boxes:

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.

Are you a parent or guardian, filling out this form on behalf of a child under 16?

Name of parent or guardian

Relationship to patient

Signed

Date

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).

Do you have a non-UK EHIC or PRC?

Yes No

If yes, please enter details from your EHIC or PRC below:

Country Code:

Name:

Given Names:

Date of Birth:

Personal Identification Number:

Identification number of the institution:

Identification number of the card:

Expiry Date:

PRC validity period:

a) From:

b) To:

Please tick if you have an S1 (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.

I have an S1 form

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.

This form is protected by reCAPTCHA and the Google Privacy Policy and Terms of Service apply.

Page last reviewed: 08 October 2021
Page created: 08 February 2019

Cookies on the The Chapel Medical Centre website

New Patient Registration Form With Child Immunisations

New Patient Registration Form With Child Immunisations

Further Information