Registration Form Step 1 of 5 20% Patient DetailsNHS Number (if known) Optional HiddenNHS Number (if known) OptionalTitle Mr Master Mrs Miss Ms Mx Sir Dr Prof First Name Middle Optional Last Name Preferred Name Optional Previous Surname Optional Date of Birth Day Month Year Gender Male Female Other Country of Birth Town of Birth Lancaster Address Street Address Address Line 2 City Postcode Home Telephone Number OptionalMobile Telephone Number OptionalEmail Address Optional Are you returning from the armed forces? Yes No Address Before Enlisting Street Address Address Line 2 City Postcode AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Service/Personnel No. Enlistment Date Day Month Year Address before moving to Lancaster Street Address Address Line 2 City Postcode AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Have you been previously registered with a UK GP Practice? Yes No Name and Address of previous GP Are you from Overseas? Yes No Date you first came to live in the UK. Day Month Year Signature of Patient OptionalSigned on behalf of Patient OptionalDate Day Optional Month Optional Year Optional Are you ordinarily resident in the UK? Yes No 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.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. 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 tick 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. Are you a parent or guardian, filling out this form on behalf of a child under 16? Yes Optional No Optional Name of Parent or Guardian Relationship to Patient: Date Day Month Year 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. NON-UK EUROPEAN HEALTH INSURANCE CARD (EHIC), PROVISIONAL REPLACEMENT CERTIFICATE (PRC) DETAILS and S1 FORMS 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 the GP practice, including at hospital).Do you have a non-UK EHIC or PRC? Yes Optional No Optional Further InformationAre you a University student? Yes No Name of University studying at Course end date Day Month Year Are you a carer for someone? Yes No Name, address, telephone number, care provided and GP of person you care forIs someone a carer for you? Yes No Name, address, telephone number, care provided and GP of person caring for youHow would you describe your ethnicity?Please SelectWhite: BritishWhite: IrishWhite: Irish TravellerWhite: Traveller Gypsy/RomanyWhite: PolishAny other white backgroundMixed: White and Black CaribbeanMixed: White and Black AfricanMixed: White and Asian⃝Any other Mixed backgroundAsian or Asian British: IndianAsian or Asian British: PakistaniAsian or Asian British: BangladeshiAny other Asian backgroundBlack or Black British: CaribbeanBlack or Black British: AfricanBlack or Black British: SomaliBlack or Black British: NigerianAny other Black backgroundOther ethnic group: ChineseOther ethnic group: FilipinoAny other ethnicNot stated: Not Stated should be used where the PERSON has been given the opportunity to state their ETHNIC CATEGORY but chose not to.Please state other Main spoken language Do you require communication assistance? Large print British Sign Language Interpreter – If an interpreter is necessary, please inform us each time you book an appointment None Are you an Armed Forces Veteran? Yes No Are you completing this form on behalf of a child under 18 years old? Yes Optional No Optional Do they have a social worker? Yes No Do you agree to receive messages from the Practice? If you opt out this will include opting out of appointment invites and appointment reminders.Via SMS Yes No Via Email Yes No Health DetailsBlood Pressure Optional Pulse Optional Height (cm) Optional Weight (kg) Optional Waist Circumference (in) Optional Medical HistoryCurrent and past Medical / Surgical / Mental Health Conditions and Year of DiagnosisConditionYear of diagnosisLast review date (if known) Add RemoveDo you have any allergies? Yes No AllergiesWhat are you allergic to?Details of reaction Add RemoveAre you on repeat medication? Yes – You will need to make an appointment to see either a Pharmacist or a GP to obtain your next prescription. No Family History Have any of your immediate relatives (brothers/sisters/parent) had any of the following? Please tick boxes and give details if possible Heart attack or angina before aged 60 Yes No Relationship to you and details OptionalHeart attack or angina over aged 60 Yes No Relationship to you and details OptionalHigh Blood Pressure Yes No Relationship to you and details OptionalAsthma Yes No Relationship to you and details OptionalDiabetes Yes No Relationship to you and details OptionalStroke Yes No Relationship to you and details OptionalCancer Yes No Relationship to you and details OptionalAny inherited disease Yes No Relationship to you and details OptionalAre you a smoker? Yes – If you would you like support and/or information on giving up, please contact the NHS Smoking Cessation Service on 0800 196 2638 No Ex-smoker How many do you smoke a day? when did you stop? Day Month Year Do you drink alcohol? Yes No How many units per week? Is there anything else you feel we should know about your health? (e.g. currently pregnant) Optional Do you use contraception? Yes No Which contraception do you use? Contraceptive pill Mirena Coil Copper coil Implanon Condoms Other Please state other: What date was this fitted / inserted: Day Month Year Summary Care RecordsThe NHS in England has introduced the Summary Care Record, which is used in emergency care. The record will only contain information about any medicines you are taking, allergies you suffer from and any bad reactions to medicines you have had to ensure those caring for you have enough information to treat you safely. Your Summary Care Record will be available to authorised healthcare staff providing your care anywhere in England, but they will ask your permission before they look at it. This means that if you have an accident or become ill, healthcare staff treating you will have immediate access to important information about your health. Lancaster Medical Practice is supporting Summary Care Records, but as a patient you have a choice. If you would like a Summary Care Record, then you do not need to do anything and a Summary Care Record will be created for you. If you do not want a Summary Care Record, please select the opt out below. For more information, please visit: NHS Digital: Summary Care Records, or telephone the dedicated NHS Summary Care Record Information Line on 0300 123 3020. Consent I agree to having a Summary Care I DO NOT want a Summary Care Record Sharing your Data for anything other than your Personal Care & The National Data Opt-Out Patients’ personal confidential data is extracted and shared with NHS Digital in order to support vital health and care planning and research. Further information about how your data is shared can be found on the NHS Digital website. Patients may opt out of having their information shared for Planning or Research by applying a National Data Opt Out and/or a Type 1 Opt Out. See below or go to the NHS website for more information: Choose If Data From Your Health Records is Shared for Research and Planning. Type 1 Opt-out (Opting out of NHS Digital collecting your data) Complete the type 1 opt-out form on our website: Type 1 Opt-Out Form, and post to the surgery or email to us at [email protected] You can: register a Type 1 Opt-out, for yourself or for a dependent (if you are the parent or legal guardian of the patient) (to Opt-out). withdraw an existing Type 1 Opt-out, for yourself or a dependent (if you are the parent or legal guardian of the patient) if you have changed your preference (Opt-in). National Data Opt-out (opting out of NHS Digital sharing your data with other organisations) You will need to either: Go to the NHS website. It will be useful to have your NHS number and an up-to-date email address or mobile phone number in your GP record which will be used to identify you. Call the NHS Digital Contact Centre on 0300 303 5678, Available Monday to Friday between 9am and 5pm (excl Bank Holidays). Download the National Data Opt-out form which you can complete & return by Post. You can also make or change a choice for your children under the age of 13, or for someone you can legally make decisions for (You must have legal authority to make a choice for someone else, e.g. by Power of Attorney). These are both done by post, you can download the forms on the NHS website: Other Ways to Make a Choice About Sharing Data. The practice is not able to process your National data opt-out for you.Declaration – your registration I understand this is not an automatic registration and I will be contacted by email once my registration is processed which can take up to 28 days. If you require medical assistance in the meantime, please call the practice on 01524 551551.
