New Patient Registration

Patient's details

Surname *

Previous Surname/s

First Name *

Date of Birth *

Please use format dd/mm/yyyy

NHS number

Which of the following best describes how you think of yourself? *

Male

Female

Non-binary

Prefer to self-describe

Is your gender identity the same as the sex you were assigned at birth? *

Yes

No

We are asking for this information to match your GP record.

Telephone Number *

Email Address *

Any correspondence will go to this address

Home Address *

Postcode *

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?

Yes

No

Name of previous GP practice

Your previous address in the UK

Address of previous GP practice

Overseas Patients

Are you from abroad?

Yes

No

Your first UK address where registered with a GP

Armed Forces

Have you ever been registered with an Armed Forces GP?

Yes

No

Please indicate your Armed Forces status

Regular

Reservist

Veteran

Family Member (Spouse, Civil Partner, Service Child)

Address before enlisting

Postcode

Service or Personnel number

Signature

Signature of patient *

Signature on behalf of patient

Date

NHS Organ Donor registration

For more information on organ donation please visit: www.organdonation.nhs.uk

NHS Blood Donor registration

Do you want to register your details on the NHS Blood Donor Register as someone who may be contacted and would be prepared to donate blood? *

Yes

No

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

Signature confirming consent to join the NHS Blood Donor Register

Date

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

Postcode

All blood types are needed, especially O negative and B negative. Visit www.blood.co.uk or call 0300 123 23 23.

Supplementary Questions

I am not ordinarily a resident in the UK

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 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.

A parent/guardian should complete the form on behalf of a child under 16.

Signature

Print Name

Date

On behalf of

Relationship to patient

European Economic Area(EEA) Country

Do you live in another EEA country, or have moved to the UK to study or retire, or live in the UK but work in another EEA member state?

Yes

No

Do you have a non-UK European Health Insurance Card (EHIC) or Provisional Replacement Certificate (PRC)?

Yes

No

If you are visiting from another EEA country and do not hold a current EHIC, PRC or S1, you may be billed for the cost of any treatment received outside of the GP practice, including at a hospital.

Country Code

Name

Given Names

Date of Birth

Please use format dd/mm/yyyy

Personal Identification Number

Identification number of the institution

Identification number of the card

Expiry Date

PRC validity period - From

To

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)?

Yes

No

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

Your choice for SCR

Express consent for medication, allergies, and adverse reactions only

Express consent for medication, allergies, adverse reactions and additional information

Express dissent (opted out) - I do not want a Summary Care Record

By including additional Information in a patient's SCR, more information is available to health and care staff viewing the SCR e.g. Paramedics

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)

I would like my information shared through the Gloucestershire shared health and a social care information project

I do not want my information shared through the Gloucestershire shared health and social care information project

SMS texting service

We offer a Text Messaging service to remind patients about their future appointments along with important announcements and information about your care.

This service is only available if you have a valid mobile number and if you are aged 16 and over.

If you are over 16 the mobile number must be yours and not a parent or guardians.

Forename

Surname

Address

Home phone number

Mobile phone number

I give consent to opt in to the text messaging service

I do not give consent and would like to opt out of the text messaging service

Occasionally the GP may wish to communicate your test results with you. If you are happy to receive this information via text message please tick this box. This will save you having to call the surgery for each result when it has been checked.

By agreeing to this you are agreeing that your phone is personal to you and any data you receive regarding your results will be accessed by only you or you are happy for those who access your phone to see these results. You will not receive every result by text, sometimes we may send a text message to ask you to call the surgery to arrange an appointment regarding your results. If you have not heard anything from us and you are concerned please still call the surgery as usual.

I confirm that the above details are correct and true.

If you are signing on behalf of the patient above, please enter your details below and your relationship to the patient (e.g. parent, guardian, attorney).

Full Name

Relationship to patient

Signature

Date

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

Please state other ethnic group

Please specify your religion or faith:

First Language

Do you speak English?

Yes

No

Do you read English?

Yes

No

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

Past Medical History

Immunisations

Please list any immunisations/vaccinations you have had or are outstanding

Past operations

Major Illnesses (please include dates)

Current medications

Sight

Good

Poor

Registered Blind

Hearing

Good

Poor

Partially Deaf

Deaf

Lifestyle

Exercise

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)

Height:

Weight:

Alcohol Consumption

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+ may indicate higher risk drinking.

Smoking

Smoking Status

Current smoker

Ex-smoker

Never smoked

How many did/do you smoke per day?

Are you interested in advice on how to quit?

Yes

No

Allergies

Do you have any drug allergies?

Yes

No

Do you have any other allergies?

Yes

No

Please specify what you are allergic to, what happens and when you had your first reaction

Adult Females

What was the result of your last cervical smear?

Have you had a hysterectomy?

Yes

No

What type of hysterectomy?

Do you still have your ovaries?

Yes

No

Carers

Do you have a carer?

Yes

No

Are you a carer for someone?

Yes

No

Emergency Contact

Full Name

Relationship to you

Telephone Number

Are they your next of Kin?

Yes

No

Consent

Would you like to set up a password to give consent for a person you trust to access results/medical information on your behalf?

Yes

No

What is the person's name you would like to authorise consent to? *

Please enter a password for your nominated person to quote if they call in *

Please enter a password hint for your nominated person to quote if they call in *

Online Services

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

Yes

No

Declaration

*

I declare that the information I have given on this form is correct and complete. I understand that if it is not correct, appropriate action may be taken against me

Signature: *

Print Name: *

On behalf of:

Relationship to patient:

Date

To be completed by the GP practice

To complete your registration, please upload proof of identity, this should include photographic ID and proof of address.

Maximum upload size: 20.97MB

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