Have
you ever registered
with this practice before?
Yes
No
* Title:
Mr Mrs Miss Ms
* Surname:
* First
name(s):
Previous surname(s):
* Date of birth:
Day
01
02
03
04
05
06
07
08
09
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
Month
January
February
March
April
May
June
July
August
September
October
November
December
Year
2024
2023
2022
2021
2020
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
2009
2008
2007
2006
2005
2004
2003
2002
2001
2000
1999
1998
1997
1996
1995
1994
1993
1992
1991
1990
1989
1988
1987
1986
1985
1984
1983
1982
1981
1980
1979
1978
1977
1976
1975
1974
1973
1972
1971
1970
1969
1968
1967
1966
1965
1964
1963
1962
1961
1960
1959
1958
1957
1956
1955
1954
1953
1952
1951
1950
1949
1948
1947
1946
1945
1944
1943
1942
1941
1940
1939
1938
1937
1936
1935
1934
1933
1932
1931
1930
1929
1928
1927
1926
1925
1924
1923
1922
1921
1920
1919
1918
1917
1916
NHS No. (if known):
Find your NHS number...
* Gender:
Male
Female
Other
Gender at birth: (if different from
above)
Male
Female
* Town and country
of birth:
Please fill in your NEW HOME ADDRESS:
Block/Floor/Flat/Room/Number:
House:
* Street:
* Town:
* Postcode:
* Mobile telephone
number:
* E-mail address:
* Confirm e-mail address:
* May we contact you using email?
Yes
No
* May we contact you using SMS text?
Yes
No
* Full name:
EMERGENCY CONTACT
* Phone no:
* Relationship:
* Are you an ARMED FORCES VETERAN?
Yes
No
Please help us
trace your medical records by selecting if you are
from UK or from
abroad (Part 1) and then filling in the next
section (Part 2)
* Part 1.
Select if you are from UK or abroad:
From UK
From abroad
Part 2: Fill in if you come
from abroad
* Date
when you arrived in UK:
Day
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
Month
January
February
March
April
May
June
July
August
September
October
November
December
Year
2024
2023
2022
2021
2020
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
2009
2008
2007
2006
2005
2004
2003
2002
2001
2000
1999
1998
1997
1996
1995
1994
1993
1992
1991
1990
1989
1988
1987
1986
1985
1984
1983
1982
1981
1980
1979
1978
1977
1976
1975
1974
1973
1972
1971
1970
1969
1968
1967
1966
1965
1964
1963
1962
1961
1960
1959
1958
1957
1956
1955
1954
1953
1952
1951
1950
1949
1948
1947
1946
1945
1944
1943
1942
1941
1940
1939
1938
1937
1936
1935
1934
1933
1932
1931
1930
1929
1928
1927
1926
1925
1924
1923
1922
1921
1920
1919
1918
1917
1916
1915
1914
1913
1912
1911
1910
1909
1908
1907
1906
1905
1904
1903
1902
1901
1900
Have you lived or studied in the UK
before?
Yes
No
Your
last UK Address where registered with
a GP
(only if you have
previously registered with a GP)
Block/Floor/Flat/Room/Number:
House:
Street:
Town:
Postcode:
Approximate
Date of
first living at this
address:
Day
01
02
03
04
05
06
07
08
09
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
Month
January
February
March
April
May
June
July
August
September
October
November
December
Year
2024
2023
2022
2021
2020
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
2009
2008
2007
2006
2005
2004
2003
2002
2001
2000
1999
1998
1997
1996
1995
1994
1993
1992
1991
1990
1989
1988
1987
1986
1985
1984
1983
1982
1981
1980
1979
1978
1977
1976
1975
1974
1973
1972
1971
1970
1969
1968
1967
1966
1965
1964
1963
1962
1961
1960
1959
1958
1957
1956
1955
1954
1953
1952
1951
1950
1949
1948
1947
1946
1945
1944
1943
1942
1941
1940
1939
1938
1937
1936
1935
1934
1933
1932
1931
1930
1929
1928
1927
1926
1925
1924
1923
1922
1921
1920
1919
1918
1917
1916
If a previous resident in UK, date of
leaving:
Day
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
Month
January
February
March
April
May
June
July
August
September
October
November
December
Year
2024
2023
2022
2021
2020
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
2009
2008
2007
2006
2005
2004
2003
2002
2001
2000
1999
1998
1997
1996
1995
1994
1993
1992
1991
1990
1989
1988
1987
1986
1985
1984
1983
1982
1981
1980
1979
1978
1977
1976
1975
1974
1973
1972
1971
1970
1969
1968
1967
1966
1965
1964
1963
1962
1961
1960
1959
1958
1957
1956
1955
1954
1953
1952
1951
1950
1949
1948
1947
1946
1945
1944
1943
1942
1941
1940
1939
1938
1937
1936
1935
1934
1933
1932
1931
1930
1929
1928
1927
1926
1925
1924
1923
1922
1921
1920
1919
1918
1917
1916
1915
1914
1913
1912
1911
1910
1909
1908
1907
1906
1905
1904
1903
1902
1901
1900
Supplementary Questions:
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
of 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,
exemption 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 purpose 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 options: More information...
Complete
the following section if you
come from another EEA country:
Do not
complete this section if you have an EHIC issued by the UK.
Do you have a
non-UK EHIC or PRC ?
Yes
No
Tick here if you have an S1
(e.g. if 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). Please give your S1 form to the practice
staff. More information...
How will your EHIC/PRC/S1 date 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 purpose 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.
*
Signature:
Health Questionnaire
Physical Activities and Eating
Habits:
Which best describes your normal
exercise pattern per week?
Select...
Excercise impossible
Avoid exercise
Light exercise
Moderate exercise
Heavy exercise
Competitive athlete
Which best describes your normal
eating pattern?
Select...
High fat
Moderate fat
Low fat
Vegetarian
Please tick if you have, or have had,
any of the following ILLNESSES:
Please list
any other existing or past
SIGNIFICANT MEDICAL CONDITIONS
including major operations and dates:
Please list
any CURRENT MEDICATION,
including
inhalers and contraception. Please specify dose:
Please
list any significant
FAMILY HISTORY of illness:
Please list
any DRUG ALLERGIES
or ALLERGIC REACTIONS:
* Do you SMOKE?
Yes
No
Used
to smoke
Do you have a
Disability or Special Communication Needs?
Yes
No
* NHS Records
There are strict laws and regulations to ensure that
your health records are kept confidential and can
only be accessed by health professionals directly
involved in your care. There is some sharing of
information as detailed below. You can opt out of
any of these at any time if you wish.
NHS Summary Care Record (SCR) -
this is an electronic record which contains
information about the medicines you take, allergies
you suffer from and any bad reactions to medicines
you have had. Having this information stored in one
place makes it easier for healthcare staff to treat
you in an emergency, or when your GP practice is
closed.
I
agree to opt in
I
do not agree to
opt in
Organ Donation
Organ donation in England has changed to
an 'opt out' system. You still have a choice
about whether or not you wish to become
a donor and your faith, beliefs and culture
will continue to be respected. You can
record your organ donation decision on the
NHS Organ Donor Register . Tell your
family and friends what you have decided.
Blood Donation
If you are
interested in becoming an blood donor,
please click this link
to go to the
blood donor registration page.
Please read our
Privacy Notice .
The information you are submitting will be sent encrypted to
the medical practice over the Internet, which still isn't
100% secure.