If you are human, leave this field blank.
Town and Country of birth
Please help us trace your previous medical records by providing the following information
Have you previously been registered with another GP?
Name of previous GP practice
Your previous address in the UK
Address of previous GP practice
Your first UK address where registered with a GP
NHS Organ Donor registration
To be completed by the GP practice
These questions and the patient declaration are optional and your answers will not affect your entitlement to register or receive services from your GP.
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 select 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.
A parent/guardian should complete the form on behalf of a child under 16.
On behalf of
Relationship to patient
Personal Identification Number
Identification number of the institution
Identification number of the card
PRC validity period - From
Do you have an S1 (e.g. are you retiring to the UK or have you been posted here by your employer for work or 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.
Sharing and receiving data
Your patient record will be held securely and confidentially on our electronic system. If you require treatment in another NHS healthcare setting such as an Emergency Department or Minor Injury Unit, those treating you would be better able to give you appropriate care if some of the information from the GP practice were available to them.
This information is your summary care record.
Please view the
Summary Care Record page so you can make informed decisions on the next section.
NHS Summary Care Record
SCR with Additional information can be added (upon request to your GP practice) which includes:
Significant problems (past and present)
Significant procedures (past and present)
Anticipatory care information
End of life care information – as per EOLC dataset ISB 1580
Gloucestershire shared health and social care information (JUYI/EMIS Shared) (Used locally across Gloucestershire)
Your Choice for Gloucestershire shared health and social care information (JUYI)
New Patient Questionnaire
A parent or guardian should complete this form on behalf of a child under 16
Please specify which ethnic group you consider you belong to
I do not wish to state
Other ethnic group
Please state other ethnic group
Female patients aged 12 and over from abroad – Do you know your rubella status? If you have no record of this vaccination please book and appointment with our practice nurse to have this vaccination
Please specify the religion or faith you consider yourself to belong to
Past Medical History
Please list any immunisations/vaccinations you have had or are outstanding
Major Illnesses (please include dates)
Please state how much exercise and what type you do per week (e.g. none, inactive, gentle, moderate, vigorous, routinely)
Eating Habits and Type of diet
(e.g. good, poor, moderate, vegetarian, vegan, meat eater)
Family history illnesses (please include dates)
How often do you have a drink that contains alcohol?
How many units of alcohol do you drink on a typical day when you are drinking?
How often have you had 6 or more units if female, or 8 or more if male, on a single occasion in the last year?
A total of 5+ indicates a higher risk drinking. An overall score of 5 or above is AUDIT-C positive.
Do you have any drug allergies?
Do you have any other allergies?
Please specify what you are allergic to, what happens and when you had your first reaction
Are you a carer for someone?
You can register for online services through our administration office on the surgery website. This will help you manage your healthcare and order repeat prescriptions and make appointments at the click of a button. If you wish to benefit from this service please register after completing this form as you will then only need to bring your ID in once.
Would you like us to set you up with a pin for online services? This means you can access your medical record, see your results, order repeat prescriptions online, make and cancel appointments and update your contact details
On behalf of
Relationship to patient