Application to Register with a General Medical Practitioner

About This Form

Some fields 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

Confidentiality

By using this form you will be sending information about yourself across the Internet. Whilst every effort is made to keep this information secure, you should be aware that we cannot offer any guarantees of absolute privacy.

Also, by sending this form you are indicating your agreement that the surgery may contact you by email or telephone to discuss the information contained in this form.

If either of these points concerns you or you disagree in any way then you should use another method of notifying us of your change of contact details.

Personal Information

Personal information retained on this system is stored in a secure data centre located in the UK and is treated as confidential.

 

Patient’s Details – Please complete the text boxes and tick where appropriate
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
If you are registering a child under 5
If you need your doctor to dispense medicines and appliances



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.

Please tick the boxes that apply:


Signature confirming consent to organ donation



Date



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

NHS Blood Donor Registration

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


Signature confirming consent to inclusion on the NHS Blood Donor Register



Date



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

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

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.

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.

Signed:________________

Date Signed:_____________

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.
NON-UK EUROPEAN HEALTH INSURANCE CARD (EHIC), PROVISIONAL REPLACEMENT CERTIFICATE (PRC) DETAILS and S1 FORMS
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?

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

PRC validity period

a) From:

b) To:

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.

CORONAVIRUS (COVID-19) ADVICE

Do not leave home if you or someone you live with has either a high temperature or a new, continuous cough or loss/change to sense of smell or taste.

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