New patient registration combined form

URL

This field is for validation purposes and should be left unchanged.

Patient's details

First names(Required)

Surname(Required)

Previous surnames

NHS Number

Get help to find your NHS number online

Town and country of birth(Required)

House name/number(Required)

Please use your current address

Street name(Required)

Please use your current address

Town/city(Required)

Please use your current address

Postcode(Required)

Please use your current address

Mobile phone number

Home phone number

Preferred phone number(Required)

Alternative phone number

Please state which School/Nursery they attend

Please provide a contact number for the School/Nursery

Please give the name/s of those who have parental responsibility(Required)

Relationship to child

Phone number/s of those with parental responsibility

Legal status if the child is living with foster carers

Register as a New Patient

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

We are now going to ask you some questions to help trace your health records from your previous GP in the UK. If you are new to the UK we will create a new health record for you. It is important to fill out as much detail below as possible.

Name and address of previous GP in UK

(If you are not new to the UK)

Please provide your previous address in UK

Please include your postcode

If you are from abroad

Registering with the NHS for the first time in the UK

First UK address where you registered with a GP

Please include postcode

If you are returning from abroad

Previously been registered with the NHS in the UK

Supplementary questions

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. Alternatively for more information go to Visiting or moving to England.

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.

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.

Type your full name to show you agree to this declaration

On behalf of

Relationship to child

European Economic Area (EEA) Country

Country code

Name

Given names

Personal Identification Number

Identification number of the institution

Identification number of the card

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.

Demographics

Anyone in England can register and consult with a GP without charge. A practice cannot refuse an application on the grounds of race, ethnicity, gender, age, marital status, religion, sexual orientation, appearance, disability, medical condition or immigration status. Any demographic information you choose to provide will be used to help us ensure that we deliver the highest quality care to all.

Communication needs

What is your main spoken language?

Please specify how we can meet your information or communication needs (for example large print, Braille, easy read)

Please specify your accessibility needs and how we can help:

Disability

Were you ever registered with an Armed Forces GP

Please provide your UK address before enlisting:

Service or Personnel number

Immigration status

Carers

Who do you care for?

Name of carer

Address

Phone number

Please give the name and contact details of the social worker

Please give the names of any other adults living in the family home

Emergency contact

Full name

Relationship to you

Phone number

Please provide the name of the school they attend:

Are they at the same address as you?

Your health

What is your height?

What is your weight?

What do you smoke?

How many per day?

How many did you smoke per day?

When did you stop?

Please state how much exercise and what type of exercise you do per week:

Adult Females only

What was the result of the cervical smear?

Please write below if you have any further comments about the cervical smear test

What type of hysterectomy?

Please give names and dates of birth of any children

Alcohol consumption - How many units of alcohol do you consume in a week?

Approximately - 1 drink = 1/2 pint of beer or 1 glass of wine or 1 single spirits. 1 unit of alcohol = 10cc of alcohol. So, a small glass (125cc) of 12% wine is 12.5 * 0.12 = 1.5 units. Find out more about alcohol units on the NHS website

Family history

Do you have any significant family history we should be aware of?

Medical history

Major illnesses

Please list any major illnesses include dates they occurred

Past operations

Please list details of any operations and dates

Family history illnesses

Please list the illnesses and dates these occurred

Current medication

Please list any current medication you have been prescribed

Students

Over 75 years old?

The Department of Health has advised that all patients of 75years and older 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.

Allergies

Allergy details

Immunisation history

Please list any immunisations or vaccinations you have had

Summary Care Record

Having read the information regarding your choices on the link below, please choose one of the options.

What happens to my information?

I certify that the information I have provided is correct and consent to my personal and medical information being used as stated above.

Signature(Required)

Please type your name to sign this form

New patient registration combined form

Patient's details

Register as a New Patient

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

If you are from abroad

If you are returning from abroad

Supplementary questions

Not ordinarily resident in the UK

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

Demographics

Communication needs

Disability

Were you ever registered with an Armed Forces GP

Immigration status

Carers

Emergency contact

Your health

Adult Females only

Alcohol consumption - How many units of alcohol do you consume in a week?

Family history

Medical history

Students

Over 75 years old?

Allergies

Immunisation history

Summary Care Record

What happens to my information?

Policy

Helpful links