New Patient Registration

Please complete this form for registering a patient 16 and over.

If you have never registered with a GP practice in the UK before, and if you are also applying for online patient access, you will be required to produce photographic ID at the practice. Please complete all information on the form. It will delay the registration process if we must contact you for missing information.

Please write ‘N/A’ if anything does not apply to you.

To register as a new patient you will need to live within our practice boundary.

Once registered, please do join our Patient Participation Group, a forum for patients and staff to improve and develop services within the practice by co-production.

New Patient Registration (Adult) - SRS

Patient's Details

Please use this date format: DD/MM/YYYY.
Gender *
Any responses we send will go to this email address.
Please use this date format: DD/MM/YYYY. Please state 'N/A' if not applicable.
Are you able to read, write and speak English fluently? *
Do you require an interpreter? *
Do you consent to receiving text messages from the practice?
Do you consent to receiving email messages from the practice?
Do you consent to receiving phone calls from the practice?
Do you consent to receiving letters in the mail from the practice?

Emergency Contact

Are they your next of kin? *
Do you give consent for this person to have access to your records? *

Previous details in the UK

Please include postcode.
Please state 'N/A' if not applicable.

If you are returning from abroad

Previously been registered with the NHS in the UK
Please use this date format: DD/MM/YYYY.
Please use this date format: DD/MM/YYYY.

Supplementary Questions

I am not ordinarily a resident in the UK

Ordinarily Resident

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 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.

European Economic Area (EEA) Country

For a list of EEA countries visit: www.gov.uk/eu-eea
Do 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?
Do you have a non-UK European Health Insurance Card (EHIC) or a Provisional Replacement Certificate (PRC) ?

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 of the GP practice, including at a hospital.

EHIC/PRC

Please enter the details from your EHIC or PRC below.

S1 Form

Do you have an S1 Form?
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.

Carer Information

Do you act as a carer for another person?
Do you have another person acting as your carer?

Carer for someone

Is the person cared for a patient of this practice?

Person acting as your carer

Are they a patient of this practice?

Communication, Accessibility, Disability and Special Needs

Do you have special communication needs?
Do you have significant restricted mobility?
Are you housebound or bedridden?
Are you partially sighted or registered blind?
Are you hearing impaired, partially or completely?
Do you have any other special needs about which you would like to tell us?

Service Families and Military Veterans

As a practice, we fully support the Armed Forces Covenant. We can only do this if we know our patients’ connections to the Armed Forces.
Please select one of the following (if applicable):

Ethnicity

We ask about your ethnicity, as this relates to certain groups of the general population being more, or less susceptive to health risks, illnesses, diseases, conditions, treatments and management. Having information about patients’ ethnicity and cultural heritage helps the NHS to plan and provide appropriate services to meet patients’ needs.
Please specify the ethnic group you consider you belong to: *

Religious Affiliation

Having information about patients’ religious affiliation also helps us to plan and provide appropriate services to meet patients’ needs.
State 'N/A' if you do not wish to answer this question