The fields marked "REQUIRED" are compulsory. You should only send this form if you are sure you are eligible to join this practice. Your details will be held at the surgery for a limited period of time. Sending this form does NOT guarantee or even imply that you will be accepted onto the practice register. If you are registering a child aged 6 or under, please ensure you complete the childrens health questionnaire that is on a seperate form in order to complete registration.
Last Updated: 22/03/2022
Student Information ( ONLY APPLICABLE TO STUDENTS)
Please help us trace your previous medical records by providing the following information
If you are from abroad
Were you ever registered with an armed forces GP?
These questions are optional and your answers will affect your entitlement to register or recieve services from the NHS but may improve access to some NHS priority and service charities services.
Information about you
Cervical Smears and contraception
Next of Kin
Contacting You / Online services
NON-UK EUROPEAN HEALTH INSURANCE CARD (EHIC), PROVISIONAL REPLACEMENT CERTIFICATE (PRC) DETAILS AND S1 FORMS - MANDATORY COMPLETETION FOR ALL EU CITIZENS
You must complete this section if you are a european citizen, 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).
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.
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, nati onals of countries outside the European Economic Area must also have the status of ‘indefnite 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 leafet, 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 confrm any details you have provided.