New Patient Registration Form - (GMS1) - Adults

Fields marked "REQUIRED" are compulsory. You should only send this form if you are sure that you are eligible to join this practice. You can check your post code on our website.

Your details will be held at the surgery for a limited period of time. Sending this form does NOT guarantee that you will be accepted onto the practice register.

This form is for patients aged 13 and over. If you are registering a patient under the age of 13, please fill in our Child New Patient Registration Form.

Patient's Details

Title

First name(s) *

Surname *

Previous Surname

Birth Town *

Birth Country *

District *

Date of Birth *

NHS number. If you do not have an NHS number, for example because you have just entered the UK, please write "no NHS number" *

Sex *

Male

Female

Address *

Postcode *

Telephone *

Email address

I am a student at:

Marital Status *

Other - Specify

Next of kin and relationship *

For patients aged 65 and over or those with a chronic disease (e.g. asthma or diabetes)

Have you had a flu vaccination? Enter the date of your most recent vaccination, or write 'never'

Have you had a pneumococcal (pneumonia) vaccination? Enter the date of your most recent vaccination, or write 'never'

Thank you for submitting your form

We will contact you to let you know if your registration has been accepted.

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

You must answer these questions. If you do not have a previous address in the UK or a previous GP in the UK, please write "no previous address" or "no previous GP".

Your previous address in UK. Please give your full address - postcodes only will not be accepted. *

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)

Enlistment date

Discharge date (if applicable)

Address before enlisting

Service or Personnel number

What is your ethnic group?

Please tick one box that best describes your ethnic group or background from the options below:

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 on the NHS website.

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.

By completing this section, you declare that the information you give on this form is correct and complete. You declare that you understand that if it is not correct, appropriate action may be taken against you.

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

(If filling out on behalf of a child under 16) name of parent/guardian

Relationship to patient:

Signed

Date

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

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. 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 No

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

Country Code:

Name:

Given Names:

Date of Birth

Personal Identification Number:

Identification number of the institution:

Identification number of the card:

Expiry Date:

PRC validity period

a) From:

b) To:

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.

I have an S1 form

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.

Summary Care Record

Your Summary Care Record is a short summary of your GP medical records. It tells other health and care staff who care for you about the medicines you take and your allergies.

All patients registered with a GP have a Summary Care Record, unless they have chosen not to have one. The information held in your Summary Care Record gives health and care professionals, away from your usual GP practice, access to information to provide you with safer care, reduce the risk of prescribing errors and improve your patient experience.

Please tick here if you do NOT want a Summary Care Record

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 individual written agreement between a patient and their GP pracitce.

This contract is between - NAME and DATE OF BIRTH *

Acceptable Behaviour Contract

This contract is between you and Ifield Medical Practice, and is valid from the date shown below.

Ifield Medical Practice will ensure that you are dealt with quickly, fairly and in a courteous and helpful manner.

Ifield Medical Practice will ensure that staff take responsibility for resolving or dealing with your query or that they refer it to an appropriate colleague.

The conditions:

The above named person applying for the registration at the practice agrees to the following:

- To refrain from using abusive or offensive language, making threats of violence or aggressive behaviour and to treat all staff fairly and with respect; in person, on the phone, in writing or social media.

- To utilise the practice's complaints process to raise concerns about care or service recieved, rather than posting anonymous feedback on social media.

- To cancel any appointments they are unable to attend with as much notice as possible

- To adhere to Ifield Medical Practice's repeat prescription policy and agree to allow 3 working days before collecting a repeat prescription

If the above named-person fails to adhere to the above conditions, they may be removed from the practice list. This contract serves as an initial warning in the event of breaches occurring.

Declaration - I confirm that I understand the meaning of this contract and that the consequences of breaking the conditions of the contract - Signature *

I confirm

Date signed *

Complete Registration

Signature

Signature of patient

Signature on behalf of patient

Signed

Date

New Patient Questionnaire

Information and Communication Needs

What is your first language? *

Do you need an interpreter? *

Yes No

Do you have any special communication needs? *

Other - please specify

Do you consent to receive SMS and/or Email communications? This will be used for messages like appointment reminders and invitations for vaccinations. *

Yes - SMS

Yes - Email

Medical history

Medications

If your prescriptions go to a pharmacy electronically, this will not be changed automatically. To make sure your prescriptions are not sent to your old pharmacy, please tell us which pharmacy you would like your medication to be sent to.

Your nominated pharmacy for prescriptions - please provide name and full address/postcode

Please list any medications you take regularly, including the dose

Do you take un-prescribed Aspirin on a daily basis which you have purchased from a chemist

Yes No

Are you allergic to any medications, for example penicillin? *

Yes No

If yes, which medications are you allergic to?

Family history

Please state any serious illness, in particular cancer, heart disease, stroke, high blood pressure, diabetes or any inherited disease. Please state your relationship to the individual and in the case of cancer, the type of cancer.

Smoking history

Do you smoke? *

Yes, I smoke

No, but I used to smoke

No, I have never smoked

If you used to smoke, when did you stop?

If you currently smoke, how many cigarettes or ounces of tobacco do you smoke per week?

Would you like advice on giving up smoking?

Yes No

Alcohol

Please ignore the number in brackets, this is for admin use only.

How often do you have a drink that contains alcohol? *

How many alcoholic drinks do you have on a typical day when you are drinking? *

How often do you have 6 or more alcoholic drinks on one occasion? *

Carers

Do you have a carer? *

Yes No

If yes, please give details

Are you a carer for someone else? *

Yes No

If yes, please give details

For women and patients assigned female at birth

Have you ever had a cervical smear test?

Yes No

Are you currently pregnant?

Yes No

Have you ever had any children? If yes, please provide their ages.

Have you ever had a miscarriage? If yes, please provide date

Have you ever had a termination of pregnancy? If yes, please provide date

Have you had a hysterectomy (an operation to remove your womb)? If yes, please provide date

Are you using any type of contraception? If yes, what type?

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Page last reviewed: 28 March 2023
Page created: 05 September 2022

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New Patient Registration Form - (GMS1) - Adults

New Patient Registration Form - (GMS1) - Adults

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