New Patient Registration

Title

First names

Surnames

Previous surnames

Date of BirthDD/MM/YYYY

Gender

Town and country of birth

NHS Number

Address

Home Telephone

Work Telephone

Mobile Telephone

Marital Status

Occupation

Can we contact you via email and/or SMS with appointment details, test results or health campaigns?

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

Previous address in UK

Name of previous GP practice while at that address

Address of previous GP practice

If you are from abroad

First UK address where registered with a GP

Date first came to live in UK

If previously resident in UK, date of leaving

Were you ever registered with an Armed Forces GP

Please indicate if you have served in the UK Armed Forces and/or been registered with a Ministry of Defence GP in the UK or overseas:

Address before enlisting

Service or Personnel number

Enlistment date

Discharge date: (if applicable)

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 statements

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

Declaration

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.

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 of the GP practice, including at a hospital.

Do you have a non-UK EHIC or PRC

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 from

PRC validity period to

Do 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).If yes please provide the surgery with a copy

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.

About You

Height (specify if in Feet/ inches or cm)

Weight (specify of in Stones/ lbs or kg)

Your main or 1st language Spoken/ Understood

Mental Health

Do you have any mental health issues?

If yes please give details

Are you receiving or have you received any treatment or therapy?

If yes please give details of your care and when you received it

Carers

Do you have a carer?

If yes, please give details

Are you a carer?

If yes, please give details

Living Will

A Living Will is documentation regarding your personal wishes in respect of medical intervention at the time of serious illness)

Do you hold a Living Will?

Women only

Date of your last smear test:

Where did the test take place?

What was the result of the smear test?

Smoking

Do you smoke?

If you do currently smoke, how many cigarettes or ounces of tobacco do you smoke per week?

Would you like advice on giving up smoking?

Alcohol Consumption

How often do you have 6 or more units if female, or 8 or more if male, on a single occasion?

How often during the last year have you been unable to remember what happened the night before because you had been drinking?

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

Has a relative or friend, doctor or other health worker been concerned about your drinking or suggested that you cut down?

Family History

Are there any serious diseases that affect your Parents, Brothers or Sisters? In particular cancer, heart disease, stroke, high blood pressure, diabetes or any inherited disease. Provide your relationship to the individual. If cancer please provide the type of cancer.

Next Of Kin Details

Next of Kin Name

Next of Kin Telephone

Relationship to next of kin

For patients aged 65 and over, or those with a chronic disease

What was the date of your last flu vaccination?

If you have had the pneumococcal vaccination, provide the date of vaccination

Privacy Protection

Information submitted through secure forms is used only for the purposes of processing your request. We may be in touch with you in relation to the information submitted.

All Information submitted through secure forms is secured with a private key and is accessed over a secure connection by nominated staff. We have a strict confidentiality policy.

This information is not shared with any third party organisations.

This information is retained for up to 28 days.

I consent to my information being used for the purposes described above and wish to submit this online form to East Park Medical Practice • Jonesfield Crescent, East Park, Wolverhampton, West Midlands, WV1 2LW.

Learn more about our Privacy Policy and Terms of Use. Should you have any concerns about sending your personal details using the web, please use one of the alternative methods offered by our organisation.

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