Patient’s Details – Please complete the text boxes and tick where appropriate
Surame
Field is required
Previous Surame
First Name
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Field is required
DOB
Birth Town
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Field is required
Birth Country
Field is required
Telephone
Post Code
Please enter valid UK number
Please enter valid UK post code
NHS number
I am a student at
Please enter valid NHS number
Address
Please help us trace your previous medical records by providing the following
Name of previous GP while at previous address
Address of that Doctor
Your previous address in UK
If you are from abroad
If previously resident in UK, date of leaving
Date you first came to live in UK
Your first UK address where registered with a GP
If you are returning from the armed forces
Service/Personnel No.
Enlistment date
Address before enlisting
If you are registering a child under 5
If you need your doctor to dispense medicines and appliances
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)
Preferred address for donation
Post Code for donation
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 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.
Name parent or guardian
Relationship to patient
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:
Country Code
Given Names
Names
Date of Birth
Personal Identification Number
ID of institute
Identification number of the card
Card Expire Date
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.
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