Patient registration form – Boothstown Medical Centre

Patient's details

Title(Required)

First names(Required)

Surname(Required)

Previous surnames

Date of birth(Required)

NHS Number

Get help to find your NHS number online

Town and country of birth(Required)

House name/number(Required)

Please use your current address

Street name(Required)

Please use your current address

Postcode(Required)

Please use your current address

Home phone number

Mobile phone number

Preferred phone number(Required)

Alternative phone number

Do you consent to us sending you text messages relating to your care e.g. appointment reminders and when we need you to contact the surgery?(Required)

Yes

Email address(Required)

Enter Email Confirm Email

Can we contact you by email?(Required)

Yes

Are you a student?(Required)

Yes

Are you registering a child?(Required)

Yes

Does this child attend a Local Authority School/Nursery?(Required)

Yes

Please state which School/Nursery they attend

Please provide a contact number for the School/Nursery

Please give the name/s of those who have parental responsibility(Required)

Relationship to child

Phone number/s of those with parental responsibility

Legal status if the child is living with foster carers

Register as a New Patient

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

We are now going to ask you some questions to help trace your health records from your previous GP in the UK. If you are new to the UK we will create a new health record for you. It is important to fill out as much detail below as possible.

Name and address of previous GP in UK

(If you are not new to the UK)

Please provide your previous address in UK

Please include your postcode

If you are from abroad

Registering with the NHS for the first time in the UK

Date you came to live in the UK

First UK address where you registered with a GP

Please include postcode

If you are returning from abroad

Previously been registered with the NHS in the UK

Date you left the UK

Date you returned to the UK

Supplementary questions

Are you ordinarily resident in the UK?

Yes

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. Alternatively for more information go to Visiting or moving to England.

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

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.

Type your full name to show you agree to this declaration

On behalf of

Relationship to child

Today's date

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?

For a list of EEA countries visit: www.gov.uk/eu-eea

Yes

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

Yes

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 (a) From:

PRC validity period (b) To:

Do you have an S1 Form?

I have an S1 form (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 you have an S1 form, please give this to the practice staff.

Yes I have an S1 form

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.

Demographics

Anyone in England can register and consult with a GP without charge. A practice cannot refuse an application on the grounds of race, ethnicity, gender, age, marital status, religion, sexual orientation, appearance, disability, medical condition or immigration status. Any demographic information you choose to provide will be used to help us ensure that we deliver the highest quality care to all.

Marital Status

Sex and gender identity - Which one of the following best describes you?

Is the gender you identify with the same as your sex registered at birth?

Yes

Prefer not to say

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

Please specify the ethnic group you consider you belong to:

Asian

Black

African

Caribbean

Other

Mixed/Multiple ethnic groups

White and Asian

White and Black African

White and Black Caribbean

Other

White

English, Welsh, Scottish, Northern Irish or British

Gypsy or Irish Traveller

Irish

Other

What is your main religion?

Communication needs

Do you speak English?(Required)

Yes

Do you read English?(Required)

Yes

What is your main spoken language?

Are you a British Sign Language user?

Yes

Do you have any specific information or communication needs?(Required)

Yes

Please specify how we can meet your information or communication needs (for example large print, Braille, easy read)

Do you have any accessibility needs?(Required)

Yes

Please specify your accessibility needs and how we can help:

Disability

Do you have an impairment, health condition or learning difference that has a substantial or long term (over a year) impact on your ability to carry out day to day activities? (Tick all that apply)

Were you ever registered with an Armed Forces GP

Have you served in the UK Armed Forces and/or been registered with a Ministry of Defence GP in the UK or overseas?

Yes

Please provide your UK address before enlisting:

Service or Personnel number

Enlistment date

Discharge date

Immigration status

What is your current immigration status?

Regardless of immigration status, you can still register and consult with a doctor at a GP surgery without charge. Please tick if either of the following apply.

I am currently seeking asylum

I have been refused a claim to asylum in the UK

Carers

Do you have caring responsibilities?

None

Primary carer of a child/children (under 18)

Primary carer of disabled child/children

Primary carer of disabled adult (18 and over)

Primary carer of older person

Secondary carer (another person carries out the main caring role)

Prefer not to say

Who do you care for?

Do you live at the same address?

Yes

Are they registered at this practice?

Yes

Do you have a carer?

Yes

Name of carer

Address

Phone number

Do you give us permission to discuss your medical record with your carer?

Yes

Are you or have you ever been a looked after child?(Required)

Yes

A child who has been in the care of their local authority for more than 24 hours is known as a looked after child/child in care.

Do you or your family have a social worker?(Required)

Yes

Please give the name and contact details of the social worker

Please give the names of any other adults living in the family home

Emergency contact

Title

Full name

Relationship to you

Phone number

Are they under 16?

Yes

Please provide the name of the school they attend:

Are they at the same address as you?

Are they your next of kin?

Yes

Do you give us permission to discuss your medical records with them?

Yes

Your health

What is your height?

What is your weight?

Smoking status

Current smoker

Ex-smoker

Never smoked

What do you smoke?

How many per day?

Are you interested in advice on how to quit?

Yes

How many did you smoke per day?

When did you stop?

Please state how much exercise and what type of exercise you do per week:

Do you have access to secure housing?

Yes

If not, are you?

Adult Females only

When was the date of your last cervical smear?

Was it done at?

A previous GP

A family planning clinic

What was the result of the cervical smear?

Please write below if you have any further comments about the cervical smear test

Have you had a hysterectomy?

Yes

What type of hysterectomy?

Do you still have your ovaries?

Yes

Please give names and dates of birth of any children

Alcohol consumption - How many units of alcohol do you consume in a week?

Approximately - 1 drink = 1/2 pint of beer or 1 glass of wine or 1 single spirits. 1 unit of alcohol = 10cc of alcohol. So, a small glass (125cc) of 12% wine is 12.5 * 0.12 = 1.5 units. Find out more about alcohol units on the NHS website

How often do you have a drink containing alcohol?(Required)

How many units of alcohol do you drink on a typical day when you are drinking?(Required)

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?(Required)

Family history

Do you have any significant family history we should be aware of?

Medical history

Major illnesses

Please list any major illnesses include dates they occurred

Past operations

Please list details of any operations and dates

Family history illnesses

Please list the illnesses and dates these occurred

Current medication

Please list any current medication you have been prescribed

Sight

Good

Poor

Registered blind

Hearing

Good

Poor

Partially deaf

Deaf

Students

I am less than 24 years old and have had two doses of the MMR Vaccination

Yes

Unsure

I am less than 25 years old and have had a Meningitis C Vaccination

Yes

Unsure

Over 75 years old?

The Department of Health has advised that all patients of 75years and older have a named and accountable GP to oversee their care. Please ask the name of the GP assigned to oversee your care. Please note this does not prevent you from seeing the GP of your choice.

Allergies

Do you have any allergies?(Required)

Yes

Allergy details

Immunisation history

Please list any immunisations or vaccinations you have had

Summary Care Record

Do you consent to having a Summary Care Record?(Required)

What happens to my information?

I certify that the information I have provided is correct and consent to my personal and medical information being used as stated above.

Signature(Required)

Please type your name to sign this form

Today's date(Required)

Not for urgent medical help(Required)

Yes, I understand this form is NOT for urgent medical help

Comments

This field is for validation purposes and should be left unchanged.