Online Registration Form If you are new to the area and wish to register with the Practice please complete the form below – each person registering will need to complete a form. Step 1 of 7 14% Patient DetailsTitle Mr Mrs Miss Ms Mx Dr Other NHS Number Find my NHS Number. Required if you have previously been registered with a GP in the UK, otherwise enter ‘000-000-0000’.First Names Surname Previous Surname Optional Date of Birth Day Month Year Gender Male (including Trans Men) Female (including Trans Women) Non Binary Other Other Gender (Please State) Occupation Optional Town and Country of Birth Address Street Address Address Line 2 City Postcode Mobile Phone NumberHome Phone Number OptionalWork Phone Number Optional Can we contact you by text?Please Select..YesNoEmail Enter Email Confirm Email Can we contact you by email?Please Select..YesNoEthnicityPlease specify the ethnic group you consider you belong to White British White Irish Black Caribbean Black African Black Caribbean and White Black African and White Indian Pakistani Bangladeshi I do not wish to state Other Other Nationality Do you speak English? Yes No Do you read English? Yes No First Spoken Language Emergency ContactFull Name Contact NumberRelationship to you Are they your next of kin? Yes No Do you give us permission to discuss your medical records with them? Yes No AllergiesDo you have any allergies? Yes No Please specify what you are allergic to, what happens and when you had your first reactionPrevious DetailsPlease help us trace your previous medical records by providing the following information:Your previous address in the UK Street Address Optional Address Line 2 Optional City Optional Postcode Optional Name of doctor while at that address Optional Address of previous doctor Street Address Optional Address Line 2 Optional City Optional Post Code Optional Armed ForcesWere you ever registered with an Armed Forces GP? Yes No Armed Forces Service DetailsPlease 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 Street Address Optional Address Line 2 Optional City Optional Postcode Optional 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 Optional Service or Personnel number Enlistment Date DD slash MM slash YYYY Discharge date (if applicable) Optional DD slash MM slash YYYY 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. If you do not wish to tell us you were in the armed forces simply answer ‘No’ to the question ‘Were you ever registered with an Armed Forces GP’. If you are from abroadRegistering with the NHS for the first time in the UKAre you from abroad and registering with the NHS for the first time in the UK? Yes Optional No Optional Date you first came to live in the UK Day Month Year Are you returning from abroad? Yes Optional No Optional Previously been registered with the NHS in the UKDate you left the UK Day Month Year Date you returned to the UK Day Month Year Supplementary QuestionsUK Residency I am not ordinarily a resident in the UK Optional 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 www.nhs.uk/visitingengland 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 or guardian should complete the form on behalf of a child under 16.Declaration Please Tick Here to confirmPrint Name On behalf of Optional Relationship to patient Optional Date Day Month Year European Economic Area (EEA) CountryFor a list of EEA countries visit: www.gov.uk/eu-eeaDo 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? Yes Optional No Optional Do you have a non-UK European Health Insurance Card (EHIC) or a Provisional Replacement Certificate (PRC) ? Yes Optional No Optional f 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 of the GP practice, including at a hospital.Please enter the details from your EHIC or PRC below.Country Code 3. Name 4. Given Names 5. Date of Birth Day Month Year 6. Personal Identification Number 7. Identification number of the institution 8. Identification number of the card 9. Expiry Date Day Month Year PRC validity period from PRC validity period to Do you have an S1 Form? I have an S1 form Optional 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.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. CarersDo you have a carer? Yes No Are you a carer for someone? Yes No Carer Name Optional Carer Telephone Number Optional Carer's Address Street Address Optional Address Line 2 Optional City Optional Post Code Optional 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 Optional Do you give us permission to discuss your medical record with your carer? Yes Optional No Optional LifestyleHeight Weight Smoking Status Current Smoker Ex Smoker Never Smoked Tell us more about your smoking history (include when you gave up) What do you smoke? e.g. Cigarettes, Vape, CigarsHow many do you smoke per day? Are you interested in advice on how to quit? Yes No Please state how much exercise and what type of exercise you do per week OptionalAlcohol ConsumptionThis is one unit of alcohol: Half pint of regular Beer/Lager/Cider 1 small glass of wine 1 single measure of spirits 1 single measure of aperitifs 1 small glass of sherry Each of these is more than one unit: Pint of regular Beer/Lager/Cider (2 Units) Pint of Premium Beer/Lager/Cider (3 Units) Alcopop or can/bottle of regular Lager (1.5 Units) Can of Premium Lager/Strong Beer (2 Units) Can of super strength lager (4 Units) Glass of wine (2 Units) Bottle of wine (9 Units) How often do you have a drink containing alcohol? Never Monthly or less 2-4 times per month 2-3 times per week 4+ times per week How many units of alcohol do you drink on a typical day when you are drinking? 1-2 3-4 5-6 7-9 10+ 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? Never Less than monthly Monthly Weekly Daily or almost daily Medical HistoryHave you had a Smear Test? Yes No Please give the date of your last smear test Day Month Year What was the result? Normal Abnormal Where was this smear test taken? Enter name and address of the clinicMajor Illnesses OptionalPlease include datesPast Operations OptionalPlease include datesFamily History Illnesses OptionalPlease include datesCurrent Medication OptionalNominated Pharmacy Optional Enter the name of the pharmacy where you collect your medication (if applicable)Last Blood Pressure Reading (if known) Optional Enter Systolic BP value over Diastolic BP value. For example: 120 over 80Sight Good Poor Registered Blind Hearing Good Poor Partially Deaf Deaf Immunisation HistoryPlease list any immunisations/vaccinations you have had OptionalPlease include datesYour Health RecordWhat is your health record? Your health record contains all the clinical information about the care you receive. When you need medical assistance it is essential that clinicians can securely access your health record. This allows them to have the necessary information about your medical background to help them identify the best way to help you. This information may include your medical history, medications and allergies. Why is sharing important? Health records about you can be held in various places, including your GP practice and any hospital where you have had treatment. Sharing your health record will ensure you receive the best possible care and treatment wherever you are and whenever you need it. Choosing not to share your health record could have an impact on the future care and treatment you receive. To find out more see Your Health Record on theNHS websiteDo you consent to your GP Practice sharing your health record with other organisations who care for you? Yes (recommended option) No, never Do you consent to your GP Practice viewing your health record from other organisations that care for you? Yes (recommended option) No, never Summary Care Record (SCR)What is your Summary Care Record? Your Summary Care Record contains basic information including your contact details, NHS number, medications and allergies. This can be viewed by GP practices, Hospitals and the Emergency Services. If you do not want a Summary Care Record, please ask your GP practice for the appropriate opt out form. With your consent, additional information can be added to create an Enhanced Summary Care Record. This could include your care plans which will help ensure that you receive the appropriate care in the future. For further information seeSummary Care Record on the NHS websiteDo you consent to having a Summary Care Record? Yes (recommended option) No Do you consent to having an Enhanced Summary Care Record with Additional Information? Yes (recommended option) No Patient ParticipationWould you like to receive occasional communications from our Patient Participation Group? Yes No Named GPThe Department of Health has advised that all patients 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.Your Medical Information – Sharing Your DataUnder the General Data Protection Regulations (GDPR), we have a responsibility to keep your medical records confidential. We need your consent to share this with other authorised health professionals involved in your care or in planning your care. You can find more information on the website at www.nhs.uk/your-nhs-data-matters. Please see the privacy notice on our website for more information on how your data is held and used by the practice. The NHS wants to make sure you and your family has the best care now and in the future. Your health and adult social care information supports your individual care. It also helps us to research, plan and improve health and care services in England. There are very strict rules on how this data can and cannot be used, and you have clear data rights. We are committed to keeping patient information safe and will always be clear on how it is used. You can choose whether or not your confidential patient information is used for research and planning. If you do not wish your information to be used in this way please opt-out by visiting NHS: Your Data Matters or by calling 0300 303 5678. The practice is unable to record this for you.NHS Organ Donor registrationFor more information on organ donation please visit: www.organdonation.nhs.ukNHS Blood Donor registrationIf you would like to join the NHS Blood Donor Register as someone who may be contacted and would be prepared to donate blood, please visit their website on: www.blood.co.uk or call direct on 03001232323What happens to my information?Personal and medical information about patients registered at this practice are primarily kept electronically, although some is kept in paper form. Some information will be sent to hospital consultants and other health professionals to whom you are referred by your GP in order to provide continued healthcare and obtain treatment for you. We sometimes use accredited suppliers for our communication with you, for example when we send recall letters for review clinics or medication reviews. All suppliers we use are checked carefully to ensure they comply with strict confidentiality protocols. To ensure the security of all patient information, all staff that has access to your records is covered by confidentiality clauses in their contracts and the Data Protection Act and the Freedom of Information Act. Our guiding principle is that we hold your records in strict confidence. SignatureDeclaration I certify that the information I have provided is correct and consent to my personal and medical information being used as stated above. Optional Signature Your Full NameDate Day Month Year Comments OptionalThis field is for validation purposes and should be left unchanged.