Patient Registration Form 2023

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: 14/09/2023

Patient Details

Title

First Name(s) *

Surname *

Previous surname(s)

Date of birth (If aged 6 years and under please ensure you complete child health questionnaire after submitting this registration) *

Sex *

NHS Number

Address *

Postcode *

Birth Town *

Birth Country *

Telephone (Please provide us with a UK telephone number as we are unable to make contact with overseas telephone numbers) *

Email address *

Please state your occupation

Student Information ( ONLY APPLICABLE TO STUDENTS)

I am a student at:

College Address:

Length of stay in Cambridge:

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

Your Previous Address in the UK

Name of previous GP practice while living at that address

Address of previous GP Practice

If you are from abroad

Your first UK address where registered with a GP

What date did you arrive in the UK?

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.

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

Address before enlisting

Service or Personnel number

Information about you

Alcohol questionnaire

Medical Information

Carers

Do you have a carer?

Yes No

If yes, please give details of who cares for you:

Are you a carer?

Yes No

If yes, please give details:

Cervical Smears and contraception

Have you ever had a cervical smear?

Yes No

If yes, please give most recent cervical smear result and what year:

Do you have any of the following contraceptive devices insitu?

IUD

Mirena Coil

Contraceptive Implant

If yes, please provide us with the date of insertion:

Please provide us with the date of the devices expiry:

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:

Next of Kin

Please give name, address, telephone number and relationship of next of kin: *

Please give an emergency contact name and telephone number:

Contacting You / Online services

Declaration

I declare that the information I give on this form is correct and complete. I understand that if it is not correct, appriopriate action may be taken against me.

Yes No

Are you the parent or guardian filling out this form on behalf of a child under 16?

Yes No

Name or parent or guardian and please state relationship to patient:

Please sign and date:

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).

Do you have a non-UK EHIC or PRC?

Yes No

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

Country Code:

Personal Identification Number:

Identification number of the institution:

Identification number of the card:

Expiry Date:

PRC validity period (Please state From and 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.

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.

Please tick one of the following boxes in relation to the statement above:

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

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Patient Registration Form 2023

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