New Patient Registration Form - Lancaster Medical Practice

GMS1

"*" indicates required fields

Step 1 of 2

50%

Patient's Details

NHS Number Optional

Prefix

Name*

First Name Surname

Previous Surname

Previous Surname Optional

Date of Birth*

DD slash MM slash YYYY

Address*

Street Address Address Line 2 City Post Code

Birth Town*

Birth Country*

Contact Number*

Are you a student?*

Yes

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

Previous Address*

Street Address Address Line 2 City Post Code

Name and Address of previous GP while at previous address,*

If you are from abroad

Your first UK address where registered with a GP

Street Address Optional Address Line 2 Optional City Optional County Optional Post Code Optional

If previously resident in UK, date of leaving Optional

DD slash MM slash YYYY

Date you first came to live in UK Optional

DD slash MM slash YYYY

If you are returning from the armed forces

Address before enlisting

Street Address Optional Address Line 2 Optional City Optional County Optional Post Code Optional

Service/Personnel No. Optional

Enlistment date Optional

DD slash MM slash YYYY

If you are registering a child under 5

I wish the child above to be registered with the named doctor for Child Health Surveillance Optional

If you need your doctor to dispense medicines and appliances

I live more than 1 mile in a straight line from the nearest chemist Optional

I would have serious difficulty in getting them from a chemist Optional

Signature of Patient Optional

Name Optional

Signature on behalf of Patient Optional

Name Optional

Date*

DD slash MM slash YYYY

NHS Organ Donor Registration

I want to register my details on the NHS Organ Donor Register as someone whose organs/tissue may be used for transplantation after my death. Please tick the boxes that apply:

Any of my organs and tissue or Optional

Kidneys Optional

Heart Optional

Liver Optional

Corneas Optional

Lungs Optional

Pancreas Optional

Any part of my body Optional

For more information, please ask for the leaflet on joining the NHS Organ Donor Register

Signature confirming consent to organ donation Optional

Name Optional

Date Optional

DD slash MM slash YYYY

NHS Blood Donor Registration

For more information, please ask for the leaflet on joining the NHS Blood Donor Register

I would like to join the NHS Blood Donor Register as someone who may be contacted and would be prepared to donate blood. Optional

Tick here if you have given blood in the last 3 years Optional

For more information, please ask for the leaflet on joining the NHS Blood Donor Register

Signature confirming consent to inclusion on the NHS Blood Donor Register Optional

Name Optional

Date Optional

DD slash MM slash YYYY

Preferred address for donation: (if different from above, e.g. place of work)

Street Address Optional Address Line 2 Optional City Optional Post Code Optional

Supplementary questions 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 tick one of the following boxes:

I understand that I may need to pay for NHS treatment outside of the GP practice Optional

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 Optional

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. Optional

Optional

Are you a parent or guardian, filling out this form on behalf of a child under 16?

Yes Optional

No Optional

Name parent or guardian Optional

Relationship to patient: Optional

Date Optional

DD slash MM slash YYYY

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

Country Code: Optional

Name Optional

Given names Optional

Date of Birth Optional

DD slash MM slash YYYY

Personal Identification Number: Optional

Identification number of the institution: Optional

Identification number of the card: Optional

Expiry Date Optional

DD slash MM slash YYYY

PRC validity period From: Optional

DD slash MM slash YYYY

PRC validity period To: Optional

MM slash DD slash YYYY

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.

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. Optional

Please be aware that our new patient registration process is taking longer than usual. If completing our online forms, you should expect your registration to be completed in around 4 weeks.

If your registration is urgent, please give the practice a ring on one of our numbers.

Please note that we are not currently notifying patients of the completion of their registration but we are working on a solution for this. Thank you.