Combined patient registration form

Please complete this form as carefully as possible to enable us to process your registration as efficiently as possible.

Patient's details

Patient title(Required)

Patient name(Required)

First names Surnames

Patient previous surnames

NHS Number

Get help to find your NHS number online

Patient date of birth(Required)

Please select(Required)

Male

Female

Email(Required)

Enter Email Confirm your email address

Town of birth(Required)

Country of birth(Required)

Home address(Required)

Postcode(Required)

Telephone number(Required)

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

Your previous address in UK

Name of previous GP practice while at that address

Address of previous GP practice

If you are from abroad

Your first UK address where registered with a GP

If previously resident in UK, date of leaving

Date you first came to live in UK

Were you ever registered with an Armed Forces GP

These questions are optional and your answers will not affect your entitlement to register or receive services from the NHS but may improve access to some NHS priority and service charities services.

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

Regular

Reservist

Veteran

Family Member (Spouse, Civil Partner, Service Child)

Address before enlisting

Postcode

Service or Personnel number

Enlistment date

Discharge date (if applicable)

Ethnic group

Please select one answer that best describes your ethnic group or background from the options below(Required)

Please state your ethnic group or background

Supplementary questions

These questions and the patient declaration are optional and your answers will not affect your entitlement to register or receive services from your GP.

Are you ordinarily resident in the UK

Yes

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 options

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.

I agree to the statement above

I agree to the statement above and I am signing on behalf of a child under 16

Your full name (your are digitally signing the declaration above)

On behalf of (add the name of child under 16 you are signing for)

Your relationship to patient

NON-UK EUROPEAN HEALTH INSURANCE CARD (EHIC), PROVISIONAL REPLACEMENT CERTIFICATE (PRC) DETAILS and S1 FORMS

Complete this section if you live in an EU 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.

I live in another EEA country, or I have moved to the UK to study or retire, or I live in the UK but work in another EEA member state.

Yes

Do you have a non-UK EHIC or PRC?(Required)

Yes

If yes, please enter details from your EHIC or PRC below:

3: Name(Required)

Country Code(Required)

4: Given Names(Required)

5: Date of Birth(Required)

6: Personal Identification Number(Required)

7: Identification number of the institution(Required)

8: Identification number of the card(Required)

9: Expiry Date

PRC validity period (a) From:

PRC validity period (b) To:

S1 Form

Please tick if 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).

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.

Yes I have an S1 form

Ethnicity, language and religion

Patient's religion(Required)

Patient's Ethnic Origin(Required)

Your main or 1st language Spoken / Understood (select one)(Required)

Do you need an interpreter?*(Required)

Yes

Health history

What illnesses have you had & when?

What operations have you had and when?

What allergies and what reactions?

Do you have any medical problems at present?

Pharmacy nomination for prescriptions(Required)

Please ensure that you nominate a local pharmacy for your prescriptions to be sent to; these are all handled electronically

Please list any tablets, medicines or other treatments you are currently taking: (incl. dose + frequency)(Required)

Are you able to administer your own medicines?(Required)

If you answer No please detail specific issues (e.g. swallowing, opening containers)

Yes

Carer or Cared for

If you are a Carer, please state the name / address / phone number of the person you care for

If you have a Carer, please state their name / address / phone number

If you have a Carer confirm here if you wish us to disclose information about your health to your Carer.

Yes you can disclose information about my health to my carer

No do not disclose information about my helath to my carer

Summary Care Record - Please read carefully

The Summary Care Record is a copy of key information from your GP record. It provides authorised care professionals working elsewhere in the NHS with faster, secure access to essential information about you when you need care. You can choose whether you want a Summary Care Record and how much information it contains.

Please select one Summary Care Record option

I would like a Summary Care Record with Additional Information. This record includes any allergies, adverse reactions or medications you are taking, as well as significant medical history (past and present), reasons for medications, and care plan information (if any).

I would like a Summary Care Record with Core Information only This record will ONLY include the medicines you are taking, allergies you suffer from and any bad reactions to medicines you have had in the past.

I do not want a Summary Care Record No Summary Care Record will be created for you, but you are free to change your decision at any time by informing your GP practice.

Sign

Type your full name in this box to confirm your choice.

Date

Vulnerable person

Due to renewed Government guidelines when registering new patients GPs are required to ask if you or someone connected to you is classed as a vulnerable person, therefore we would be most grateful if you could answer the following 2 questions. All information provided in your answers is strictly confidential and will not be passed onto any other party.

Who do you live with?

I currently live with somebody who is classed as a vulnerable adult

I currently live with somebody who is classed as a vulnerable child

I do not live with someone classed as vulnerable

If yes, who is this person to you?

Do you have any family members classed as vulnerable?

Yes

If yes, please specify

Patient age

Is the patient you are registering under 14?(Required)

Depending on your choice here we will present different questions on the rest of the form.

The patient is under 14

The patient is 14 or over

Please bring a Passport/Red Book/Birth Certificate to confirm the date of birth. Please complete a separate form for each family member to be registered.

Please bring a Passport/Driving Licence to confirm your date of birth and address. Please complete a separate form for each family member to be registered.

Next of kin

Please give name, address, telephone number and relationship of next of kin.(Required)

Lifestyle

Smoking, Alcohol Consumption and Exercise

Are you a smoker?(Required)

Yes I am currently a smoker

I am an ex-smoker

I have never smoked

How many cigarettes / cigars / tobacco do you smoke in a week?

If you are a smoker and want to stop, please ask for information about local smoking cessation services.

How often do you exercise? Number of times per week(Required)

Type(s) of exercise

How much alcohol do you drink in a week (Units)?(Required)

(One unit = 1 small glass of wine, a single measure of spirits, or 1/2 a pint of beer)

Do you have a 'Living Will' (a statement explaining what medical treatment you would not want in the future)?

If 'Yes' can you please bring a written copy of it to your New Patient Consultation.

Yes I have a living will

No I do not have a living will

Your physical examination will include having your height, weight and blood pressure taken, and a specimen of urine for testing.
The Consultation will also establish relevant past medical and family history, including:

Medical factors - illnesses, immunisations, allergies, hereditary factors, screening tests, current health
Social factors - employment, housing, family circumstances
Lifestyle factors - diet and exercise, smoking, alcohol and drug abuse.

Parent/Guardian/Carers details

If you are completing this on behalf of a child under 14 we need more details.

Parent/Guardian/Carers name(Required)

Relationship to patient(Required)

Can we discuss medical problems with Parent/Guardian/Carer?(Required)

Yes

Parent/Guardian/Carer phone number(Required)

Next of Kin Emergency Contact Number(Required)

School setting(Required)

Patient Participation Group

The Practice is committed to improving the services we provide to our patients. To do this, it is vital that we hear from people about their experiences, views, and ideas for making services better. By expressing your interest in joining, you will be helping us to plan ways of involving patients that suit you. It will also mean we can keep you informed of opportunities to give your views and keep you up to date with developments within the Practice. If you are interested in getting involved, please tick the box below and we will arrange for the Practice Patient Participation Group Application Form to be given to you at your initial consultation.

I am interested in becoming involved in the Practice Patient Participation Group

Yes

Acceptable behaviour contract

We are committed to promoting access to our services and offering choice wherever possible in the services we provide and the way we deliver them. An acceptable behaviour contract is an individually written agreement between a patient and their GP practice. The contract is between Beaconsfield Road Surgery and the person named below, and is valid from the date shown below.

The surgery aims to:

help you as a patient to access our services
offer you choices where available
deal with you quickly and fairly as soon as possible
be polite and helpful to you

In return, we expect you as a patient to:

treat staff fairly and politely, whether on the phone, face to face, in writing, or on social media
use our complaints policy if you need to raise concerns about our care or service
attend your appointments, giving as much notice as possible if you are ever unable to attend
allow us three working days notice of any repeat prescriptions that you need

To avoid putting your place as our patient at risk, we ask you not to:

use abusive or threatening language
make threats, be violent or aggressive
fail to attend appointments

We appreciate your helping us to help you.
Declaration: I confirm that I understand the meaning of this contract and that the consequences of breaking the conditions of the contract.

Type your full name to digitally sign and agree to the acceptable behaviour contract(Required)

Today's date for this contract(Required)

Privacy consent

Not for urgent medical help(Required)

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

Consent(Required)

By submitting your details you are consenting to providing this information for improving our services to you. The data you supply on this form will be securely stored on our website, which is hosted by a third party. We will retain this information on the website for no longer than 7 calendar days. Your contact details will not be sold or shared with a third party. I understand I can revoke this consent at anytime by contacting the practice. Our privacy policy can be viewed on this website.

I agree to the privacy policy.

Phone

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